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Flores DV, Sampaio ML, Agarwal A. Ultrasound-guided injection and aspiration of small joints: techniques, pearls, and pitfalls. Skeletal Radiol 2024; 53:195-208. [PMID: 37354318 DOI: 10.1007/s00256-023-04374-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 05/27/2023] [Accepted: 05/28/2023] [Indexed: 06/26/2023]
Abstract
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.
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Affiliation(s)
- Dyan V Flores
- Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada.
- Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
- Ottawa Hospital Research Institute, ON, Ottawa, Canada.
| | - Marcos Loreto Sampaio
- Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada
- Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- Ottawa Hospital Research Institute, ON, Ottawa, Canada
| | - Aakanksha Agarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Demino C, Koesarie K, Smith J, Fowler JR. Ultrasound Use by Upper Extremity Surgeons in 2020: A Survey of ASSH Members. Hand (N Y) 2023; 18:1222-1229. [PMID: 35373624 PMCID: PMC10798197 DOI: 10.1177/15589447221082170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The use of musculoskeletal ultrasound (US) among hand surgeons appears to be increasing. The purpose of this study was to determine the utilization patterns and attitudes regarding US among American Society for Surgery of the Hand (ASSH) members in 2020 as well as the changes in usage patterns since a previous survey in 2015. METHODS In 2020, an updated and expanded 27-question survey was distributed to 4852 members of the ASSH. Questions assessed respondent demographics, training, and practice patterns, and access, utilization, training, and opinions pertaining to US. RESULTS A total of 418 surveys (8.6%) were analyzed. Compared to 2015, there was an increase in the percentage of respondents using US for diagnostic purposes (51%-68%), as well as having personal access to US machines (43% to 58%). US use to assist in diagnosing carpal tunnel syndrome increased from 19% to 27%. The most common reason for using US was convenience and practice efficiency, while the most common reasons for not using US was no machine access. In 2020, 33% of respondents performed US-guided injections. CONCLUSIONS Compared to 2015, the majority of responding upper extremity surgeons now have personal access to US machines. Utilization of diagnostic US appears to be increasing, and two-thirds of respondents believed that US use will continue to increase among upper extremity surgeons.
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Perineural Local Anesthetic Treatments for Osteoarthritic Pain. REGENERATIVE ENGINEERING AND TRANSLATIONAL MEDICINE 2021; 7:262-282. [DOI: 10.1007/s40883-021-00223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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McDevitt AW, Cleland JA, Strickland C, Mintken P, Leibold MB, Borg M, Altic R, Snodgrass S. Accuracy of long head of the biceps tendon palpation by physical therapists; an ultrasonographic study. J Phys Ther Sci 2020; 32:760-767. [PMID: 33281293 PMCID: PMC7708007 DOI: 10.1589/jpts.32.760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/22/2020] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Examination and treatment of the long head of the biceps tendon (LHBT)
requires accurate palpation. The purpose of this study was to determine physical
therapists’ reliability and ability to accurately palpate the LHBT in two arm positions
with ultrasound as the gold standard. [Participants and Methods] Examiners palpated the
LHBT within the intertubercular groove (ITG) of the humerus on the bilateral shoulders of
32 asymptomatic (21 female; 24.3 ± 1.9 years) participants in 2 arm positions. The
magnitude of distance between a marker and the border of the ITG was compared between 2
positions using an independent t-test. Percent accuracy was calculated. [Results]
Inter-rater reliability was poor (position 1, k=1.04; position 2,
k=0.016). Overall accuracy rate was 45.7% (117/256). Accuracy was 49.2%
(63/128) and 42.2% (54/128) for testing position 1 and position 2 respectively. Mean
distance palpated from the groove was M=2.58 mm (± 6.2 mm) for position 1
and M=3.77 mm (± 6.6 mm) for position 2. Inaccurate palpation occurred
medially 72.3% (47/65) and 93.2% (69/74) in position 1 and position 2 respectively.
[Conclusion] Results of this study did not support one arm position being more accurate
over another for LHBT palpation.
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Affiliation(s)
- Amy W McDevitt
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus: 13121 E. 17th Avenue, ED2S, Aurora, CO 80045, USA.,Sports Medicine and Rehabilitation, University of Colorado Health, USA.,School of Health Sciences, The University of Newcastle, Australia
| | | | - Colin Strickland
- Sports Medicine and Rehabilitation, University of Colorado Health, USA
| | - Paul Mintken
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus: 13121 E. 17th Avenue, ED2S, Aurora, CO 80045, USA
| | | | - Maria Borg
- Sports Medicine and Rehabilitation, University of Colorado Health, USA
| | - Rebecca Altic
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus: 13121 E. 17th Avenue, ED2S, Aurora, CO 80045, USA
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Kruse RC, Kindle BJ, Wisniewski S, Presley J, Smith J, Sellon JL. Local Anesthesia Prior to Ultrasound-Guided Hip Joint Injections: A Double-Blind Randomized Controlled Trial of Bacteriostatic Saline versus Buffered Lidocaine. PM R 2020; 13:811-818. [PMID: 32935453 DOI: 10.1002/pmrj.12489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/06/2020] [Accepted: 08/31/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Ultrasound (US)-guided hip joint injections are commonly performed for patients with suspected or known intra-articular hip pain. Lidocaine is a well-established local anesthetic used prior to hip joint injections, but it is often associated with discomfort during infiltration. Bacteriostatic saline is an alternative local anesthetic that has been shown to be less painful during infiltration for superficial injections. OBJECTIVE To compare infiltrative pain and anesthetic efficacy of bacteriostatic saline (0.9% benzyl alcohol) with a standard local anesthetic (buffered 1% lidocaine) used for local anesthesia prior to US-guided intra-articular hip corticosteroid injections. DESIGN Double-blinded, randomized controlled trial. SETTING Tertiary care medical center. PARTICIPANTS Sixty eight patients age 18-80 (mean 54.8) years referred for US-guided intra-articular hip corticosteroid injections. INTERVENTION Patients were randomized to receive a US-guided hip joint corticosteroid injection using either bacteriostatic saline or buffered 1% lidocaine for preinjection local anesthesia. MAIN OUTCOME MEASURES Visual Analog Scale (VAS) for pain (0-100) during local anesthetic infiltration as well as during the intra-articular injection. Adverse events were also recorded. RESULTS There were no significant differences between bacteriostatic saline and buffered lidocaine with respect to pain during local anesthetic infiltration or during the subsequent intra-articular injection. Pain VAS during local anesthetic infiltration was 13.2 (95% confidence interval [CI] 7.8, 18.5) in the bacteriostatic saline group and 14.0 (95% CI 9.4, 18.5) in the buffered 1% lidocaine group (P = .82). Furthermore, pain VAS during the intra-articular injection was 20.7 (95% CI 14.1, 27.3) in the bacteriostatic saline group and 15.7 (95% CI 10.9, 20.3) in the buffered 1% lidocaine group (P = .57). No adverse events occurred. CONCLUSIONS Bacteriostatic saline is a safe and comparably effective alternative to buffered 1% lidocaine for local anesthesia before US-guided hip joint injections and may be considered for subcutaneous/periarticular anesthesia during similar musculoskeletal procedures.
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Affiliation(s)
- Ryan C Kruse
- Department of Physical Medicine and Rehabilitation, Sports Medicine Center, Mayo Clinic, Rochester, MN, USA.,Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Brett J Kindle
- Department of Physical Medicine and Rehabilitation, Sports Medicine Center, Mayo Clinic, Rochester, MN, USA.,Andrews Institute, Gulf Breeze, FL, USA
| | - Steve Wisniewski
- Department of Physical Medicine and Rehabilitation, Sports Medicine Center, Mayo Clinic, Rochester, MN, USA
| | - James Presley
- Department of Physical Medicine and Rehabilitation, Sports Medicine Center, Mayo Clinic, Rochester, MN, USA.,Andrews Institute, Gulf Breeze, FL, USA
| | - Jay Smith
- Departments of Physical Medicine & Rehabilitation, Radiology and Clinical Anatomy, Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, MN, USA
| | - Jacob L Sellon
- Department of Physical Medicine and Rehabilitation, Sports Medicine Center, Mayo Clinic, Rochester, MN, USA
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Sederberg M, Liem B, Tarkhan A, Gessel T, LaCourse M, Latzka E. Brief Ultrasound-Aided Teaching to Improve the Accuracy and Confidence of Resident Musculoskeletal Palpation. PM R 2019; 12:391-396. [PMID: 31448538 DOI: 10.1002/pmrj.12246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/18/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multiple studies demonstrate poor musculoskeletal palpation accuracy of physiatry residents. With the growing use of ultrasound clinically, it could serve as a powerful educational tool. However, there are no published studies examining the efficacy of ultrasound-aided education at the bedside, where much learning takes place during postgraduate training. OBJECTIVE To determine if brief ultrasound-aided teaching improves residents' accuracy and confidence of musculoskeletal palpation. DESIGN Before/After Trial. SETTING Academic Institution. PARTICIPANTS Ten physical medicine and rehabilitation residents were voluntary participants. INTERVENTION Each resident was given a survey to assess confidence in palpating the hook of the hamate and medial calcaneal tubercle. They then attempted to palpate and place a marker over these two structures in a model patient. Marker placement accuracy was verified by ultrasound. Faculty spent less than 1 minute per landmark, sonographically teaching its correct localization. The resident, after moving to a new model patient, was then re-tested on accurate marker placement for both landmarks. A repeat survey to assess confidence was administered. MAIN OUTCOME MEASUREMENTS Preintervention and postintervention accuracy and confidence of correct localization of both landmarks. RESULTS We used McNemar's and Wilcoxon's tests to determine whether the intervention improved the location accuracy and confidence of successful palpation, respectively. Confidence level of correct localization of two landmarks improved on average from 4.3 to 8.15 on a scale of 10 after intervention. Of 20 palpation attempts, 11 correctly placed the marker postintervention after an incorrect placement, 8 made no change, and one changed from correct to incorrect placement. The odds of improvement in accuracy was 11 (95% confidence interval [CI] 1.60-473.47, P < .01). Both tests showed significant improvements after the intervention at the significance level of .05. CONCLUSIONS Brief, ultrasound-aided teaching increases accuracy and confidence of residents' musculoskeletal palpation.
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Affiliation(s)
- Mark Sederberg
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Brian Liem
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | | | - Trevor Gessel
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Matthew LaCourse
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Erek Latzka
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
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Strakowski JA, Visco CJ. Diagnostic and therapeutic musculoskeletal ultrasound applications of the shoulder. Muscle Nerve 2019; 60:1-6. [PMID: 31054148 DOI: 10.1002/mus.26505] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/28/2019] [Indexed: 11/10/2022]
Abstract
High frequency ultrasound is a valuable tool for assessing soft tissue injuries about the shoulder. It has advantages over other imaging modalities including relatively low cost, portability, and dynamic real-time visualization. It has a high sensitivity for identifying tendon degeneration, bursitis, and rotator cuff tears. Ultrasound is also an excellent modality for diagnostic and therapeutic needle-guided procedures. A detailed knowledge of shoulder anatomy and transducer positioning is required for obtaining adequate diagnostic value from ultrasound. This Monograph is designed to help develop scanning protocols for optimizing image acquisition for musculoskeletal assessment of the shoulder. Muscle Nerve, 2019.
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Affiliation(s)
- Jeffrey A Strakowski
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio, USA.,OhioHealth Riverside Methodist Hospital, 3555 Olentangy River Road, Columbus, 43214, Ohio, USA.,The McConnell Spine, Sport, and Joint Center, Columbus, Ohio, USA
| | - Christopher J Visco
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Dekker AP, Borton Z, Espag M, Cresswell T, Tambe AA, Clark DI. Continuing acromioclavicular joint pain after excision arthroplasty: is further surgery effective? Ann R Coll Surg Engl 2019; 101:357-362. [PMID: 31042427 DOI: 10.1308/rcsann.2019.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Little published evidence exists on the incidence of continuing acromioclavicular joint pain with no published outcomes for revision surgery. This study aimed to establish the incidence and outcomes of revision acromioclavicular joint excision surgery. MATERIALS AND METHODS A consecutive retrospective cohort of patients undergoing revision arthroscopic or open acromioclavicular joint excision was identified. Patients were identified from a prospectively collected database. Inclusion criteria were revision acromioclavicular joint excisions over a 14-year period between 2001 and 2015. Exclusion criteria were previous surgery for acromioclavicular joint instability or shoulder arthroplasty. Outcome measures were Oxford Shoulder scores and a satisfaction survey. RESULTS Forty-three consecutive cases of revision acromioclavicular joint excision over 14 years (37 after arthroscopic excision with subacromial decompression, 5 after arthroscopic excision with rotator cuff repair, 1 after open excision). Continuing acromioclavicular joint pain was associated with incomplete resection from arthroscopic surgery, which was the primary indication for revision surgery. Revision occurred a mean 14.2 months after primary surgery (standard deviation 7.6 months). Mean Oxford Shoulder score was preoperatively 18 (standard deviation 8.1) and 23.4 (standard deviation 11.1) after primary surgery, which did not reach significance until after revision surgery with a mean 31.7 (standard deviation 13.6; P = 0.021). Median follow up was 15 months (interquartile range 4-31 months). A survey at a mean of 6 years (standard deviation 2.3) post-revision surgery found that 65% of patients felt improved, 77% would have their surgery again and 69% of patients felt satisfied. The incidence of postoperative frozen shoulder was 14.3%. CONCLUSION Functional outcomes after revision surgery showed improvement from scores taken before primary surgery; however, long-term satisfaction rates were relatively low.
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Affiliation(s)
- A P Dekker
- Trauma and Orthopaedic Surgery Department, Royal Derby Hospital , Derby , UK
| | - Z Borton
- Trauma and Orthopaedic Surgery Department, Royal Derby Hospital , Derby , UK
| | - M Espag
- Trauma and Orthopaedic Surgery Department, Royal Derby Hospital , Derby , UK
| | - T Cresswell
- Trauma and Orthopaedic Surgery Department, Royal Derby Hospital , Derby , UK
| | - A A Tambe
- Trauma and Orthopaedic Surgery Department, Royal Derby Hospital , Derby , UK
| | - D I Clark
- Trauma and Orthopaedic Surgery Department, Royal Derby Hospital , Derby , UK
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Chang KV, Mezian K, Naňka O, Wu WT, Lin CP, Özçakar L. Ultrasound-guided interventions for painful shoulder: from anatomy to evidence. J Pain Res 2018; 11:2311-2322. [PMID: 30349357 PMCID: PMC6188188 DOI: 10.2147/jpr.s169434] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan,
- Department of Physical Medicine and Rehabilitation, National Taiwan University, College of Medicine, Taipei, Taiwan,
| | - Kamal Mezian
- Department of Rehabilitation Medicine, Charles University, First Faculty of Medicine, Prague, Czech Republic
| | - Ondřej Naňka
- Institute of Anatomy, Charles University, First Faculty of Medicine, Prague, Czech Republic
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan,
| | - Chih-Peng Lin
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan,
- Department of Anesthesiology, National Taiwan University, College of Medicine, Taipei, Taiwan,
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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Javed S, Sadozai Z, Javed A, Din A, Schmitgen G. Should all acromioclavicular joint injections be performed under image guidance? J Orthop Surg (Hong Kong) 2018; 25:2309499017731633. [PMID: 28933229 DOI: 10.1177/2309499017731633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Steroid and local anaesthetic injection to the acromioclavicular joint (ACJ) is a very common diagnostic and therapeutic procedure, which is often performed in the outpatient department. However, it can be difficult to localize this joint because of its small size, presence of osteophytes and variable morphology in the population. We performed a study to determine whether the use of an image intensifier (X-ray guidance), in theatre, improves the accuracy of this injection. METHODS This was a prospective study carried out between March 2014 and March 2015. The injections were performed by two senior orthopaedic surgeons. First, we clinically palpated the ACJ and marked the area over this point as A. Then, with the use of a needle and an image intensifier in a single plane, we identified the actual location of the ACJ and marked this point as B. We measured the distance between A and B in millimetres (mm) and determined the accuracy of the injections. Further analysis taking into account the ACJ capsular attachments was also performed. RESULTS In total, 45 patients and 50 injections were included in the study; five patients had repeated injections at different times. We found that only 12 injections (24%) were palpated to be correct with no discrepancies between A and B (95% confidence interval: 14-37%). For the remaining 38 injections (76%), the use of an image intensifier had significantly improved the accuracy of ACJ location ( p < 0.05). Taking the capsular attachments of the ACJ into consideration reduced the number of inaccurate injections to 27 (54%). CONCLUSION We recommend the use of an image intensifier (or ultrasound guidance) to accurately determine the location of the ACJ for steroid and local anaesthetic injections. This prevents an injection into the wrong place, which can lead to wrong diagnosis and/or suboptimal treatment.
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Affiliation(s)
- S Javed
- Trauma and Orthopaedic Department, Royal Blackburn Hospital, Blackburn, UK
| | - Z Sadozai
- Trauma and Orthopaedic Department, Royal Blackburn Hospital, Blackburn, UK
| | - A Javed
- Trauma and Orthopaedic Department, Royal Blackburn Hospital, Blackburn, UK
| | - A Din
- Trauma and Orthopaedic Department, Royal Blackburn Hospital, Blackburn, UK
| | - G Schmitgen
- Trauma and Orthopaedic Department, Royal Blackburn Hospital, Blackburn, UK
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Daniels EW, Cole D, Jacobs B, Phillips SF. Existing Evidence on Ultrasound-Guided Injections in Sports Medicine. Orthop J Sports Med 2018; 6:2325967118756576. [PMID: 29511701 PMCID: PMC5826008 DOI: 10.1177/2325967118756576] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Eldra W Daniels
- Department of Family Community Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - David Cole
- Department of Family Community Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Bret Jacobs
- Department of Orthopaedics, New York University Langone Medical Center, New York, New York, USA
| | - Shawn F Phillips
- Department of Family Community Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
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Krill MK, Rosas S, Kwon K, Dakkak A, Nwachukwu BU, McCormick F. A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review. PHYSICIAN SPORTSMED 2018; 46:98-104. [PMID: 29210329 PMCID: PMC6396285 DOI: 10.1080/00913847.2018.1413920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Michael K Krill
- a Florida Atlantic University Charles E. Schmidt College of Medicine , Boca Raton , FL , USA
- b Jameson Crane Sports Medicine Institute , The Ohio State University Wexner Medical Center , Columbus , OH , USA
| | - Samuel Rosas
- c Baptist Health, Department of Orthopedic Surgery , Wake Forest University , Winston-Salem , NC , USA
| | - KiHyun Kwon
- d Florida International University Herbert Wertheim College of Medicine , Miami , FL , USA
| | - Andrew Dakkak
- a Florida Atlantic University Charles E. Schmidt College of Medicine , Boca Raton , FL , USA
| | - Benedict U Nwachukwu
- e Department of Orthopedic Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Frank McCormick
- f Department of Orthopedics , Harvard Medical School, Beth Israel Deaconess Medical Center , Boston , MA , USA
- g Department of Sports Medicine , Harvard Medical School, Beth Israel Deaconess Medical Center , Boston , MA , USA
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13
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Woods R, Wisniewski SJ, Lueders DR, Pittelkow TP, Larson DR, Finnoff JT. Can Ultrasound Be Used to Improve the Palpation Skills of Physicians in Training? A Prospective Study. PM R 2017; 10:730-737. [PMID: 29225162 DOI: 10.1016/j.pmrj.2017.11.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 11/14/2017] [Accepted: 11/29/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited. OBJECTIVE To determine whether ultrasound can improve the ability of physicians in training (residents) to palpate the long head of the biceps tendon (LHBT) in the bicipital groove. DESIGN Prospective study design. SETTING Tertiary care center. PARTICIPANTS Ten physical medicine and rehabilitation residents served as subjects. Exclusion criteria included the presence of any condition that precluded their ability to palpate. Three volunteers were used as models. Model exclusion criteria included anything that distorted normal shoulder anatomy or inhibited examiner palpation. Three investigators with experience performing diagnostic musculoskeletal ultrasound were used to confirm palpation attempts. METHODS Subjects attempted to palpate the LHBT bilaterally in the bicipital groove of each model. Investigators assessed the accuracy of the palpation attempt using real-time ultrasonography. Subjects participated in a 30-minute ultrasound-assisted training session learning how to palpate the LHBT in the bicipital groove with ultrasound confirmation. After the ultrasound training session, subjects again attempted to palpate the LHBT in the bicipital groove of each model with investigator confirmation. MAIN OUTCOME MEASUREMENTS LHBT palpation accuracy rates preintervention versus postintervention. RESULTS Pretraining LHBT palpation accuracy was 20% (12/60 attempts). Post-ultrasound training session accuracy was 51.7% (31/60 attempts; P ≤ .001). CONCLUSIONS Our findings demonstrate that palpation accuracy improves after ultrasound assisted LHBT palpation training. These data suggest that the use of ultrasound may be beneficial when teaching musculoskeletal palpation skills to health care professionals. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Ryan Woods
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN.,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.,Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905
| | - Steve J Wisniewski
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN.,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.,Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905
| | - Daniel R Lueders
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN.,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.,Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905
| | - Thomas P Pittelkow
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN.,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.,Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905
| | - Dirk R Larson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN.,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.,Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905
| | - Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN.,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.,Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN.,Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905
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Abstract
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.
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Abstract
Background: Ultrasound is a versatile imaging modality that can be used by upper extremity surgeons for diagnostic purposes and guided injections. The perceptions of ultrasound for diagnosis and treatment among upper extremity surgeons and its barriers for adoption have not been formally surveyed. The purpose of this study is to determine the current usage of musculoskeletal ultrasound for diagnostic purposes and guided injections by upper extremity surgeons and their reasons for using it or not using it in practice. Methods: A 22-question survey was distributed to the American Society for Surgery of the Hand (ASSH). The survey questions consisted of respondent characteristic questions and questions pertaining to the use of ultrasound. Chi-square analysis was performed to assess for a difference in ultrasound usage across respondent characteristics. Results: Three hundred four (43%) answered that they have an ultrasound machine in their office; Fifty-one percent (362) of the respondents use ultrasound for diagnostic purposes. Fifty-five (8%) of the survey respondents use ultrasound to diagnose carpal tunnel syndrome; 168 (23.5%) respondents reported that they use ultrasound for guided injections. There was a statistically significant difference between access to an ultrasound machine in the office by practice setting and use of ultrasound for diagnostic purposes by practice setting. Conclusions: The use of ultrasound by upper extremity surgeons is split for diagnostic purposes, with fewer surgeons using ultrasound to diagnose carpal tunnel syndrome and guided injections. Ultrasound machine availability and the use of ultrasound for diagnosis appear to be influenced by practice setting.
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Affiliation(s)
- William L. Wang
- Department of Orthopedics, University of Pittsburgh, PA, USA
| | - Kevin Kruse
- Department of Orthopedics, University of Pittsburgh, PA, USA
| | - John R. Fowler
- Department of Orthopedics, University of Pittsburgh, PA, USA,John R. Fowler, Assistant Professor, Department of Orthopaedic Surgery, University of Pittsburgh, Suite 1010, Kaufmann Bldg., 3471 Fifth Ave., Pittsburgh, PA 15213, USA.
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Musculoskeletal interventional procedures: With or without imaging guidance? Best Pract Res Clin Rheumatol 2016; 30:736-750. [PMID: 27931965 DOI: 10.1016/j.berh.2016.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 11/22/2022]
Abstract
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).
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Intraoperative Use of Ultrasound for Identification of Acromioclavicular Joint During Shoulder Arthroscopy. Tech Orthop 2016. [DOI: 10.1097/bto.0000000000000165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Ultrasound Guidance for Technically Challenging Intrathecal Baclofen Pump Refill. Am J Phys Med Rehabil 2016; 95:692-7. [DOI: 10.1097/phm.0000000000000495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effectiveness of Ultrasound Guidance on Intraarticular and Periarticular Joint Injections: Systematic Review and Meta-analysis of Randomized Trials. Am J Phys Med Rehabil 2016; 94:775-83. [PMID: 25768070 DOI: 10.1097/phm.0000000000000260] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness and accuracy of ultrasound-guided intraarticular and periarticular joint injections as compared with landmark-guided injections technique. METHODS A systematic literature search was performed in Medline, Web of Science, Embase, the Cochrane Central Register of Controlled Trials, reference lists of articles, and other sources. Only randomized controlled trials were included. Two reviewers independently selected and assessed each study for quality and extracted data. RESULTS Twelve randomized controlled trials were included in the meta-analysis. The results indicated that ultrasound-guided intraarticular and periarticular joint injections were more accurate than the landmark-guided injections (odds ratio, 0.36; 95% confidence interval, 0.22-0.60). Ultrasound-guided joint injections significantly decreased the visual analog scale scores at both 2 wks (mean difference, -9.57; 95% confidence interval, -13.14 to -5.99) (P < 0.00001) and 6 wks (mean difference, -14.21; 95% confidence interval, -18.20 to -10.21) (P < 0.00001) after injection. There was no statistically significant difference in visual analog scale score at 12 wks between ultrasound-guided and landmark-guided intraarticular and periarticular joint injections (mean difference, -4.42; 95% confidence interval, -11.71 to 2.87) (P = 0.23). CONCLUSIONS Intraarticular and periarticular injections using ultrasound guidance significantly improves the accuracy of joint injections, and there is a significant decrease in visual analog scale scores for up to 6 wks after injection. The effect of ultrasound guidance on the long-term outcome of joint injections is inconclusive. The improved accuracy of injections was associated with pain relief. The authors recommend routine ultrasound guidance for intraarticular and periarticular injections.
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McAuliffe MB, Derrington SM, Nazarian LN. Evidence for Accuracy and Effectiveness of Musculoskeletal Ultrasound-Guided Compared with Landmark-Guided Procedures. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0103-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Resident Accuracy of Electromyography Needle Electrode Placement Using Ultrasound Verification. PM R 2015; 8:748-53. [PMID: 26690019 DOI: 10.1016/j.pmrj.2015.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 11/26/2015] [Accepted: 11/28/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Electromyography (EMG) and musculoskeletal (MSK) ultrasound (US) are core learning objectives during physical medicine and rehabilitation (PM&R) training. However, there have been no prior studies using MSK US to assess the acquisition of EMG procedural skills during residency training. This study aims to demonstrate the differences in skillful needle placement between junior and senior physiatry residents. The integration of both EMG and MSK US may have tremendous potential for additional learning opportunities related to electrodiagnostic education. OBJECTIVE To determine the accuracy of anatomic landmark-guided EMG needle electrode placement in commonly used muscles by PM&R resident physicians. DESIGN Cross-sectional study. SETTING An academic PM&R residency program. PARTICIPANTS Twelve (5 postgraduate year [PGY] -3 and 7 PGY-4) PM&R resident physicians participating in a MSK US training course. METHODS Twelve PM&R residents in the eighth month of their third and fourth years of postgraduate training performed anatomic landmark-guided needle placement to the extensor indicis proprius (EIP), pronator teres (PT), peroneus longus (PL), and soleus muscles of live subjects. Once the needle electrode was satisfactorily placed, needle localization was verified with US. MAIN OUTCOME MEASURES Accuracy of EMG needle electrode placement. RESULTS The overall accuracy of needle electrode placement for all resident participants was 68.8%. The mean accuracy of the 4 selected muscles was 50% by PGY-3 residents and 82.1% for PGY-4 residents (P = .01). EIP was the most commonly missed muscle, with correct placement performed by 20% of PGY-3 and 42.9% of PGY-4 residents. PGY-3 residents demonstrated 60% accuracy with localizing the PT, PL, and soleus muscles. PGY-4 residents demonstrated 85.7% accuracy for PT, and 100% accuracy for both PL and soleus muscles. CONCLUSIONS Senior residents demonstrated greater accuracy of landmark-guided needle placement than junior residents. EMG procedural skills are important milestones in PM&R training, and MSK US may be a useful tool to enhance resident learning.
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Finnoff JT, Hall MM, Adams E, Berkoff D, Concoff AL, Dexter W, Smith J. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. PM R 2015; 7:151-68.e12. [PMID: 25708351 DOI: 10.1016/j.pmrj.2015.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 01/09/2015] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, University of California, Davis School of Medicine, Sacramento, CA; Tahoe Orthopedics and Sports Medicine, 1139 Third St, South Lake Tahoe, CA 96150.(∗); Department of Orthopedics and Rehabilitation, Department of Family Medicine, University of Iowa Sports Medicine, Iowa City, IA(†).
| | - Mederic M Hall
- Department of Orthopedics and Rehabilitation, Department of Family Medicine, University of Iowa Sports Medicine, Iowa City, IA(†)
| | - Erik Adams
- Midwest Sports Medicine Institute, Middleton, WI(‡)
| | - David Berkoff
- Department of Orthopaedics and Emergency Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC(§)
| | - Andrew L Concoff
- Outpatient Musculoskeletal Rehabilitation, St Jude Medical Center, Fullerton, CA(¶)
| | - William Dexter
- Maine Medical Center, Portland, ME; Tufts University School of Medicine, Boston, MA(#)
| | - Jay Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN; Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN(∗∗)
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Wilson DJ, Scully WF, Rawlings JM. Evolving Role of Ultrasound in Therapeutic Injections of the Upper Extremity. Orthopedics 2015; 38:e1017-24. [PMID: 26558666 DOI: 10.3928/01477447-20151020-11] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 03/23/2015] [Indexed: 02/03/2023]
Abstract
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.
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Moon SH, Ko KP, Baek SI, Lee S. Ultrasonography and Ultrasound-guided Interventions of the Shoulder. Clin Shoulder Elb 2015. [DOI: 10.5397/cise.2015.18.3.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Chang Chien GC, Best CS, Clay BS, Candido KD. Ultrasonography Leads to Accurate Diagnosis and Management of Painful Acromioclavicular Joint Cyst. Pain Pract 2015; 15:E72-5. [DOI: 10.1111/papr.12316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 03/09/2015] [Indexed: 01/27/2023]
Affiliation(s)
- George C. Chang Chien
- Department of Pain Management; Cleveland Clinic Foundation; Anesthesiology Institute; Cleveland Ohio U.S.A
| | - Craig S. Best
- Department of Physical Medicine & Rehabilitation; Rush University Medical Center; Chicago Illinois U.S.A
| | - Brian S. Clay
- Department of Anesthesiology-Pain Medicine; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - Kenneth D. Candido
- Department of Anesthesiology; Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
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27
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Sonographically Guided Semimembranosus Bursa Injection: Technique and Validation. PM R 2015; 8:51-7. [DOI: 10.1016/j.pmrj.2015.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/12/2015] [Indexed: 12/28/2022]
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American Medical Society for Sports Medicine position statement: interventional musculoskeletal ultrasound in sports medicine. Clin J Sport Med 2015; 25:6-22. [PMID: 25536481 DOI: 10.1097/jsm.0000000000000175] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med 2014; 49:1042-9. [DOI: 10.1136/bjsports-2014-093573] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2014] [Indexed: 01/31/2023]
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Finnoff JT, Hall MM, Adams E, Berkoff D, Concoff AL, Dexter W, Smith J. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. Br J Sports Med 2014; 49:145-50. [PMID: 25330777 DOI: 10.1136/bjsports-2014-094219] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, Sacramento, California, USA Department of Physical Medicine and Rehabilitation, Mayo Clinic college of Medicine, Mayo Clinic Sports Medicine Center, Rochester, Minnesota, USA
| | - Mederic M Hall
- Department of Orthopedics and Rehabilitation, Department of Family Medicine, University of Iowa Sports Medicine, Iowa City, Iowa, USA
| | - Erik Adams
- Midwest Sports Medicine Institute, Middleton, Wisconsin, USA
| | - David Berkoff
- Department of Orthopaedics and Emergency Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrew L Concoff
- Outpatient Musculoskeletal Rehabilitation, St. Jude Medical Center, Fullerton, California, USA Department of Family Medicine, Division of Sports Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - William Dexter
- Maine Medical Center, Portland, Maine, USA Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Jay Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, Minnesota, USA Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Edelson G, Saffuri H, Obid E, Lipovsky E, Ben-David D. Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up. J Shoulder Elbow Surg 2014; 23:e243-50. [PMID: 24725899 DOI: 10.1016/j.jse.2014.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/08/2014] [Accepted: 01/12/2014] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Gordon Edelson
- Orthopedic Department, Poriya Government Hospital, Tiberias, Israel.
| | - Husam Saffuri
- Orthopedic Department, Poriya Government Hospital, Tiberias, Israel
| | - Elias Obid
- Orthopedic Department, Poriya Government Hospital, Tiberias, Israel
| | | | - Doron Ben-David
- Radiology Department, Poriya Government Hospital, Tiberias, Israel
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Intra-articular versus periarticular acromioclavicular joint injection: a multicenter, prospective, randomized, controlled trial. Arthroscopy 2013; 29:1903-10. [PMID: 24140142 DOI: 10.1016/j.arthro.2013.08.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 08/21/2013] [Accepted: 08/21/2013] [Indexed: 02/02/2023]
Abstract
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.
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Díaz RCR, Lotero MAA, Giraldo DJG. Ultrasound-guided tricompartmental blockade of the shoulder. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2013.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Sabeti M. Accuracy of acromioclavicular joint injections: letter to the editor. Am J Sports Med 2013; 41:NP45. [PMID: 24077749 DOI: 10.1177/0363546513504896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Rivera Díaz RC, Arcila Lotero MA, Giraldo Giraldo DJ. Bloqueo tricompartimental de hombro guiado por ultrasonografía. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2013.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Musculoskeletal Ultrasound in Physical Medicine and Rehabilitation. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-012-0003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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McAlindon T, Kissin E, Nazarian L, Ranganath V, Prakash S, Taylor M, Bannuru RR, Srinivasan S, Gogia M, McMahon MA, Grossman J, Kafaja S, FitzGerald J. American College of Rheumatology report on reasonable use of musculoskeletal ultrasonography in rheumatology clinical practice. Arthritis Care Res (Hoboken) 2013; 64:1625-40. [PMID: 23111854 DOI: 10.1002/acr.21836] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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The Accuracy and Efficacy of Palpation versus Image-Guided Peripheral Injections in Sports Medicine. Curr Sports Med Rep 2013; 12:296-303. [DOI: 10.1097/01.csmr.0000434103.32478.36] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Ultrasound-guided tricompartmental blockade of the shoulder☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341040-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Borbas P, Kraus T, Clement H, Grechenig S, Weinberg AM, Heidari N. The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers. J Shoulder Elbow Surg 2012; 21:1694-7. [PMID: 22475721 DOI: 10.1016/j.jse.2011.11.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/21/2011] [Accepted: 11/28/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Injections of the acromioclavicular joint (ACJ) are performed routinely in patients with ACJ arthritis, both diagnostically and therapeutically. The aim of this prospective controlled study was to estimate the frequency of successful intra-articular ACJ injections with the aid of sonographic guidance versus non-guided ACJ injections. MATERIALS AND METHODS A total of 80 cadaveric ACJs were injected with a solution containing methylene blue and subsequently dissected to distinguish intra- from peri-articular injections. In 40 cases the joint was punctured with sonographic guidance, whereas 40 joints were injected in the control group without the aid of ultrasound. RESULTS The rate of successful intra-articular ACJ injection was 90% (36 of 40) in the guided group and 70% (28 of 40) in the non-guided group. Ultrasound was significantly more accurate for correct intra-articular needle placement (P = .025). DISCUSSION The use of ultrasound significantly improves the accuracy of ACJ injection.
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Affiliation(s)
- Paul Borbas
- Department of Orthopedics, University of Zurich, Balgrist, Zurich, Switzerland.
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Guerini H, Ayral X, Vuillemin V, Morvan G, Thévenin F, Campagna R, Drapé JL. Ultrasound-guided injection in osteoarticular pathologies: General principles and precautions. Diagn Interv Imaging 2012; 93:674-79. [DOI: 10.1016/j.diii.2012.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interv Aging 2012; 7:89-95. [PMID: 22500117 PMCID: PMC3324992 DOI: 10.2147/cia.s29265] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Intra-articular corticosteroid and hyaluronic acid injections provide short-term symptom amelioration for arthritic conditions involving structural damage or degenerative changes in the knee. Conventional palpation-guided anatomical injections frequently result in inaccurate needle placement into extra-articular tissue and adjacent structures. The purpose of this review was to determine the effect of ultrasound guidance on the accuracy of needle placement, clinical outcomes, and cost-effectiveness in comparison with anatomical landmark-guided intra-articular large joint injections, with particular emphasis on the knee. A total of 13 relevant studies were identified; five studied the knee, seven studied the shoulder, one used both the knee and shoulder, and none studied the hip. Ultrasound was used in seven studies; the remaining studies utilized air arthrography, fluoroscopy, magnetic resonance arthrography, or magnetic resonance imaging. Across all studies (using all imaging modalities and all joints), needle placement accuracy ranged from 63% to 100% with ultrasound and from 39% to 100% with conventional anatomical guidance. Imaging guidance improved the accuracy of intra-articular injections of the knee (96.7% versus 81.0%, P < 0.001) and shoulder (97.3% versus 65.4%, P < 0.001). In particular, ultrasound guidance of knee injections resulted in better accuracy than anatomical guidance (95.8% versus 77.8%, P < 0.001), yielding an odds ratio of 6.4 (95% confidence interval 2.9-14). Ultrasound guidance notably improves injection accuracy in the target intra-articular joint space of large joints including the knee. The enhanced injection accuracy achieved with ultrasound needle guidance directly improves patient-reported clinical outcomes and cost-effectiveness.
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Affiliation(s)
- David J Berkoff
- Department of Orthopedics, University of North Carolina School of Medicine, Chapel Hill, USA
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Collins JMP, Smithuis R, Rutten MJCM. US-guided injection of the upper and lower extremity joints. Eur J Radiol 2011; 81:2759-70. [PMID: 22130195 DOI: 10.1016/j.ejrad.2011.10.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/12/2011] [Accepted: 10/28/2011] [Indexed: 12/13/2022]
Abstract
There is a growing interest in the application of ultrasound (US) guidance for diagnostic and therapeutic joint injections. US provides direct visualization of soft tissues and the outer borders of bony structures. With real-time needle guidance the success rate of intra-articular injections improves and iatrogenic damage to anatomic structures can be avoided. An US machine is more readily available, transferrable and more affordable than a fluoroscopy machine or CT scanner and lacks the risk of radiation. These factors make US a valuable alternative to procedures performed either blind or under fluoroscopic or CT guidance. This article focuses on the rationale for injections in the upper and lower extremity joints and describes and illustrates the different US-guided injection techniques.
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Affiliation(s)
- James M P Collins
- Department of Radiology, Medical Center Leeuwarden, H. Dunantweg 2, AD Leeuwarden, The Netherlands.
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Mautner K, Malanga G, Colberg R. Optimization of ingredients, procedures and rehabilitation for platelet-rich plasma injections for chronic tendinopathy. Pain Manag 2011; 1:523-32. [DOI: 10.2217/pmt.11.56] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
SUMMARY There is considerable interest amongst clinicians and researchers to create the optimal platelet product to maximize outcomes with platelet-rich plasma (PRP) injections. PRP has been widely introduced as a safe alternative for treating tendinopathies. However, there is still limited clinical evidence describing the components of the platelet product and supporting its use in clinical trials. This article reviews the current literature regarding the role of PRP injections in the treatment of recalcitrant tendinopathies and the different factors in the platelet product that could affect the outcome, including the platelet count, presence of leukocytes, activators used, pH of solution and delivery method, among others. In addition, we address important concepts regarding rehabilitation after PRP procedures, which has little consensus to date and is the subject of much debate. Based on the phases of soft tissue healing, basic science research on platelets, as well as our clinical experience in treating over 500 patients with PRP, we will suggest guidelines regarding the optimal progression of rehabilitation and timing for return to previous activity following the procedure.
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Affiliation(s)
| | - Gerard Malanga
- Department of Physical Medicine & Rehabilitation, University of Medicine & Dentistry, 30 Bergen Street, Newark, NJ, USA
| | - Ricardo Colberg
- Department of Physical Medicine & Rehabilitation & Department of Orthopedics, Emory University, Atlanta, GA, USA
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Peck E, Finnoff JT, Smith J, Curtiss H, Muir J, Hollman JH. Accuracy of palpation-guided and ultrasound-guided needle tip placement into the deep and superficial posterior leg compartments. Am J Sports Med 2011; 39:1968-74. [PMID: 21617254 DOI: 10.1177/0363546511406235] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Invasive leg compartment testing may be performed to diagnose chronic exertional compartment syndrome. No prior study has assessed the accuracy of leg compartment needle tip access. PURPOSE This study was undertaken to describe and determine the accuracy of palpation-guided and ultrasound-guided techniques for needle tip placement into the deep and superficial posterior leg compartments by a less experienced clinician and a more experienced clinician using a cadaveric model. STUDY DESIGN Controlled laboratory study. METHODS Twenty unembalmed adult lower limb cadaveric specimens were used for the study. Two investigators, a sports medicine fellow with 10 months of musculoskeletal ultrasound experience and a staff physiatrist with 3 years of musculoskeletal ultrasound experience, each performed 1 palpation-guided and 1 ultrasound-guided colored latex dye injection into the deep and superficial posterior leg compartments of each cadaveric specimen. A blinded investigator dissected the specimens and graded them for accuracy. RESULTS The accuracy rates of palpation-guided (accuracy rate, 90%; 95% confidence interval [CI], 76%-97%) and ultrasound-guided (accuracy rate, 88%; 95% CI, 73%-95%) deep posterior compartment injections were statistically equivalent (P = 1.000). All 80 injections performed into the superficial posterior compartment were accurate (accuracy rate, 100%; 95% CI, 89%-100%). The accuracy of the less experienced investigator (total injection accuracy rate, 88%; 95% CI, 73%-95%) and the more experienced investigator (total injection accuracy rate, 90%; 95% CI, 76%-97%) were not significantly different (P = 1.000). CONCLUSION Needle tip placement into the deep and superficial posterior leg compartments is relatively accurate with palpation guidance regardless of level of experience, and does not improve with the use of ultrasound guidance. CLINICAL RELEVANCE Ultrasound guidance does not appear to be indicated for routine deep or superficial posterior leg compartment pressure testing. However, this does not preclude the need for ultrasound guidance in selected clinical scenarios.
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Affiliation(s)
- Evan Peck
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, West Palm Beach, Florida, USA.
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Sabeti-Aschraf M. RE: Accuracy of Ultrasound-Guided Versus Palpation-Guided Acromioclavicular Joint Injections: A Cadaveric Study. PM R 2011; 3:495; author reply 495. [DOI: 10.1016/j.pmrj.2011.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 02/15/2011] [Indexed: 11/28/2022]
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Peck E. Reply. PM R 2011. [DOI: 10.1016/j.pmrj.2011.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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