Therapeutic and Diagnostic Joint Injections

Clinical impact of diagnostic image-guided injections for musculoskeletal pain work-up in adolescent and adult patients at a children's hospital: initial results

OBJECTIVE

To assess the clinical impact of diagnostic musculoskeletal (MSK) injections on treatment decision-making in adolescent and adult patients at a children's hospital.

MATERIALS AND METHODS

Retrospective study in patients who underwent diagnostic MSK injections by fluoroscopy or ultrasound (US) between 8/2020 and 3/2023 at a children's hospital. Patients received ropivacaine and triamcinolone acetonide at pain site, reporting quantitative FACES pain score prior to, immediately following, and 2-3 days following injection. Impact on patient care was subsequently assessed.

RESULTS

A total of 109 diagnostic fluoroscopic or US MSK injection referrals (mean: 17.6 years old) were included, most commonly hip (76.2%), ankle (9.2%), and iliopsoas tendon sheath (8.3%). Pain improvement occurred in 89.0% immediately and 67.9% 2-3 days after MSK injection, with net 84.4% exhibiting improvement based on pain scores and clinical exams. When there was pain improvement at the site of injection, there was a statistically higher incidence of operative intervention or additional therapeutic injections compared with the cohort that did not have symptom improvement (88% versus 35.3%, P < 0.0001). For the 15.6% (N = 17) of referrals that did not have pain improvement, 17.6% (n = 3) ultimately had an operative intervention at a separate site from the diagnostic injection, as an alternative etiology for the pain was found.

CONCLUSION

Image-guided MSK injections play an important role in the management of musculoskeletal disorders. 84.4% of referrals experienced symptom relief, improving confidence for treatment decision-making. Importantly, 15.6% of patients were found to have an alternative etiology for symptoms, altering management altogether.

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Accuracy of Intraarticular Injections: Blind vs. Image Guided Techniques-A Review of Literature

Intra-articular injections are widely used for diagnostic and therapeutic purposes of joint pathologies throughout the body. These injections can be performed blind by utilizing anatomical landmarks or with the use of imaging modalities to directly visualize the joint space during injections. This review of the literature aims to comprehensively identify differences in the accuracy of intra-articular injections via palpation vs. image guidance in the most commonly injected joints in the upper and lower extremities. To our knowledge, there are no such comprehensive reviews available. A narrative literature review was performed using PubMed and Google Scholar databases to identify studies focusing on the accuracy of blind or image-guided intra-articular injections for each joint. A total of 75 articles was included in this review, with blind and image-guided strategies being discussed for the most commonly injected joints of the upper and lower extremities. Varying ranges of accuracy with blind and image-guided modalities were found throughout the literature, though an improvement in accuracy was seen in nearly all joints when using image guidance. Differences are pronounced, particularly in deep joints such as the hip or in the small joints such as those in the hand or foot. Image guidance is a useful adjunct for most intra-articular injections, if available. Though there is an increase in accuracy in nearly all joints, minor differences in accuracy seen in large, easily accessed joints, such as the knee, may not warrant image guidance.

Complications in image-guided musculoskeletal injections

Complications in musculoskeletal interventions are rare and where they do occur tend to be minor, and often short-lived or self-limiting. Nonetheless, the potential for significant complications exists, and a thorough understanding of both the mechanisms which contribute and the manner in which they may clinically present is of critical importance for all musculoskeletal radiologists involved in performing procedures, both to mitigate against the occurrence of complications and to aid rapid recognition. The purpose of this review is to analyse the relevant literature to establish the frequency with which complications occur following musculoskeletal intervention. Furthermore, we highlight some of the more commonly discussed and feared complications in musculoskeletal intervention, such as the risk of infection, potential deleterious articular consequences including accelerated joint destruction and the poorly understood and often underestimated systemic effects of locally injected corticosteroids. We also consider both extremely rare but emergent scenarios such as anaphylactic reactions to medications, and much more common but less significant complications such as post-procedural pain. We suggest that meticulous attention to detail including strict adherence to aseptic technique and precise needle placement may reduce the frequency with which complications occur.

Osteoarthritis of the hip: are degenerative tears of the acetabular labrum predictable from features on hip radiographs?

BACKGROUND

A common feature of hip arthritis is the presence of labra tears. Recent literature suggests against the use of magnetic resonance imaging (MRI) in patients aged >45 years for the assessment of hip pain related to arthritis.

PURPOSE

To determine if radiographic features of osteoarthritis detectable on routine hip radiographs are accurate and reliable surrogate markers of degenerative acetabular labral tears identified on MR arthrography (MRA) and corroborated during arthroscopy.

MATERIAL AND METHODS

A retrospective study involving 86 symptomatic patients (hip pain) with radiologic work-up included MRA and pelvic or hip radiographs that underwent hip arthroscopy within three months. Imaging characteristics assessed on hip radiographs include measurements of superior acetabular, femoral head osteophyte, cortical thickness of the femoral shaft, and minimum joint space as well as presence of subchondral sclerosis of the femoral head and acetabulum, femoral shaft buttressing, and grade of arthritis. Presence of a labral tear was determined by consensus between three readers as well as by surgical correlation. The Pearson's chi-squared and Fisher's exact tests were used to compare presence of labral tears with each radiographic feature.

RESULTS

Seventy-one patients (82.6%) had labral tears: 49 (69%) women and 22 (31%) men. Receiver operating characteristic analysis showed statistical significance (P<0.05) between presence of a labral tear and acetabular and femoral head osteophyte sizes but failed to demonstrate any significance regarding acetabular subchondral sclerosis, cortical thickness, buttressing, or minimum joint space.

CONCLUSIONS

Radiographic markers such as the acetabular and femoral head osteophyte sizes demonstrated statistical significance with the presence of labral tears.

In-Office Needle Arthroscopy: A Systematic Review of Indications and Clinical Utility

PURPOSE

This review explores the current literature regarding both the clinical indications and utility of minimally invasive in-office needle arthroscopy (IONA) relative to conventional imaging modalities.

METHODS

In compliance with R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched in July 2018, in addition to the conference abstract databases of 5 prominent meetings between 2013 and 2018, for studies using IONA for diagnostic purposes. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Among 932 conference abstracts and 369 studies identified, 11 publications involving 404 patients (395 knees and 9 shoulders) were included, with 9 clinical studies and 2 cost analyses. The median Methodological Index for Non-Randomized Studies (MINORS) score was 9 for noncomparative and 23 for comparative studies. Among the 9 clinical studies, IONA had a superior sensitivity, specificity, positive predictive value, and negative predictive value to magnetic resonance imaging (MRI) in the evaluation of knee osteoarthritis, anterior cruciate ligament insufficiency, and meniscal tears. IONA was comparable or inferior to MRI in the same parameters for the diagnosis of osteochondral defects and rotator cuff tears. In the 2 cost analyses, IONA had lower costs when used in place of MRI for treatment algorithms involving medial meniscal tears and rotator cuff tears but not lateral meniscal tears.

CONCLUSIONS

IONA holds potential for cost savings and improved diagnostic accuracy relative to MRI, primarily for intra-articular meniscal, ligamentous, and chondral defects of the knee. However, its current indications for use in other joints are limited to rotator cuff tears in the shoulder, making its diagnostic value in other joints much more limited. The current quality and breadth of evidence are significantly lacking, with numerous practical shortcomings. To improve acceptance of IONA, priority should be placed on establishing defined protocols, indications, contraindications, and patient perspectives for the procedure.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

A prototype assembled 3D-printed phantom of the glenohumeral joint for fluoroscopic-guided shoulder arthrography

PURPOSE

To describe the methodology of constructing a three-dimensional (3D) printed model of the glenohumeral joint, to serve as an interventional phantom for fluoroscopy-guided shoulder arthrography training.

MATERIALS AND METHODS

The osseous structures, intra-articular space and skin surface of the shoulder were digitally extracted as separate 3D meshes from a normal CT arthrogram of the shoulder, using commercially available software. The osseous structures were 3D-printed in gypsum, a fluoroscopically radiopaque mineral, using binder jet technology. The joint capsule was 3D printed with rubber-like TangoPlus material, using PolyJet technology. The capsule was secured to the humeral head and glenoid to create a sealed intra-articular space. A polyamide mold of the skin was printed using selective laser sintering. The joint was stabilized inside the mold, and the surrounding soft tissues were cast in silicone of varying densities. Fluoroscopically-guided shoulder arthrography was performed using anterior, posterior, and rotator interval approaches. CT arthrographic imaging of the phantom was also performed.

RESULTS

A life-size phantom of the glenohumeral joint was constructed. The radiopaque osseous structures replicated in-vivo osseous corticomedullary differentiation, with dense cortical bone and less dense medullary cancellous bone. The glenoid labrum was successfully integrated into the printed capsule, and visualized on CT arthrography. The phantom was repeatedly used to perform shoulder arthrography using all three conventional approaches, and simulated the in vivo challenges of needle guidance.

CONCLUSIONS

3D printing of a complex capsule, such as the glenohumeral joint, is possible with this technique. Such a model can serve as a valuable training tool.

Ultrasound-Guided Steroid Injection of the Pisotriquetral Joint: A Multidisciplinary Effort

From the perspective of a multidisciplinary team, the authors describe the first reported use of ultrasound guidance for steroid injection into the pisotriquetral joint to relieve wrist pain of a person with spinal cord injury undergoing acute inpatient rehabilitation. Musculoskeletal ultrasound guidance was used to improve the accuracy of a corticosteroid injection of the pisotriquetral joint and the basal thumb in a 70-year-old man with paraplegia experiencing multifocal degenerative wrist pain. There was no bleeding or bruising after the injections, and the patient reported complete pain resolution 1 wk after the injections, which continued for over 1 yr. A multidisciplinary team was key in diagnosis, selection of treatment, and evaluation of treatment effect. Corticosteroid injection of the pisotriquetral joint under ultrasound guidance can be used as a treatment modality for managing wrist pain stemming from that joint. Further investigation and studies evaluating the use of ultrasound versus other imaging modalities for injection of the wrist are indicated.

Effect of ice on pain after corticosteroid injection in the hand and wrist: a randomized controlled trial

This prospective, randomized controlled study was designed to determine if applying ice to the site of corticosteroid injections in the hand and wrist reduces post-injection pain. Patients receiving corticosteroid injections in the hand or wrist at a tertiary institution were enrolled. Subjects were randomized to apply ice to the injection site and take scheduled over-the-counter analgesics ( n = 36) or take scheduled over-the-counter analgesics alone ( n = 32). There were no significant differences in the mean pain score between the two groups at any time-point (pre-injection or 1-5 days post-injection). In regression modelling, the application of ice did not predict pain after injection. Visual analogue pain scores increased at least 2 points (0-10 scale) after injection in 17 out of 36 patients in the ice group versus ten out of 32 control patients. We conclude that the application of ice in addition to over-the-counter analgesics does not reduce post-injection pain after corticosteroid injection in the hand or wrist.

LEVEL OF EVIDENCE

I Therapeutic Study.

Magnetic resonance arthrography and the prevalence of acetabular labral tears in patients 50 years of age and older

OBJECTIVE

Arthroscopy for acetabular labral tears has minimal impact on pain and function in older patients, especially in the setting of concomitant osteoarthritis. Still, many physicians seek this diagnosis with MR arthrography. Our purpose is to assess the frequency of acetabular labral tears in older patients with hip pain and correlate likelihood of labral pathology with severity of osteoarthritis as visualized on conventional radiograph.

MATERIALS AND METHODS

From 2004 to 2013, 208 hip MRI arthrograms and corresponding radiographs on patients aged 50 years and older were identified. Age, gender, grade and location of labral tear, alpha angle, Tönnis grade, and joint space width were documented. Labral tears and alpha angle were identified and measured on MR arthrogram. Tönnis grade and joint space width were measured on radiographs.

RESULTS AND CONCLUSIONS

On MR arthrography, true labral tearing was identified in 73 % of patients. There was some degree of labral pathology in 93.3 % of patients, and this increased to 100 % in patients with moderate to severe osteoarthritis, as defined by Tönnis grade 2-3 or joint space width ≤ 2 mm. There were no statistically significant correlations between labral tear grade and Tönnis grade or joint space width. Given the high frequency of labral pathology and the questionable efficacy of arthroscopic surgical intervention in older patients, MR arthrography should be primarily for those with minimal arthritis on radiograph and potential to benefit from surgery. If further imaging beyond radiographs is necessary in these patients, standard MRI may be a more appropriate imaging tool.

The use of arthrography in pediatric orthopaedic surgery

Surgery near pediatric joints can be challenging because it is difficult to visualize vital articular structures. Assessment of underlying pathology is also challenging because the joint structures have not yet ossified. Arthrography is a useful tool that is quick and minimally invasive and allows adequate visualization of joint anatomy during surgery, which aids intraoperative decision making. In pediatric patients, arthrography is most useful for visualization of the elbow, knee, and hip joints. This tool can help the surgeon to refine the diagnosis and management of pediatric fractures and aids in surgical assessment during joint and limb reconstruction. Arthrography adds minimal time to surgery and carries a low risk of complications; it should be part of the armamentarium of any surgeon who treats pediatric orthopaedic patients.

Musculoskeletal aspiration procedures

With advances in imaging technology, there has been a significant increase in the number and range of interventional musculoskeletal image-guided procedures. One of the most commonly performed image-guided musculoskeletal interventions is the diagnostic and therapeutic percutaneous aspiration and drainage of multiple types of intra-articular, juxta-articular, and intramuscular pathologic fluid collections. These procedures may be performed under fluoroscopic, ultrasound, computed tomography, or even magnetic resonance guidance depending on the location to be accessed, type of pathology, patient characteristics, and operator preference. Musculoskeletal image-guided aspiration and drainage procedures are minimally invasive and generally very safe while offering valuable diagnostic information as well as therapeutic benefit. This article focuses on the appropriate indications, contraindications, and general technique for accessing the major joints via imaging guidance. For each joint, we discuss pertinent anatomy, appropriate imaging modalities, and preferred approaches to gaining intra-articular access. Additionally, the article discusses some of the more frequently encountered juxta-articular and intramuscular fluid collections that can be accessed and aspirated via percutaneous intervention, with mention of the importance of recognizing extremity sarcomas that can mimic these benign collections.

The most accurate approach for intra-articular needle placement in the knee joint: a systematic review

INTRODUCTION

Intra-articular needle placement in the knee joint, such as injection or aspirations, are commonly used for therapeutic, diagnostic, and research purposes. Although several approaches can be used to establish an intra-articular injection or aspiration of the knee joint, the accuracy differs per approach.

OBJECTIVE

To summarize the evidence concerning the accuracy of different approaches for intra-articular needle placements in the knee. Additionally, to assess whether the accuracy of different approaches is related to factors such as underlying disease, severity of underlying disease, approach-related factors, and/or the rate of local reactions.

METHODS

The literature was systemically reviewed until July 2010. Risk of bias of the included studies was assessed by the QUADAS tool. Study characteristics were extracted; accuracy results were pooled per approach.

RESULTS

Nine studies were included. The superolateral approach with the leg in extension was studied most (230 injections) and resulted in the highest pooled accuracy of 91% (95% CI 84-99%). The lateral midpatellar approach, the anterolateral approach, and the anteromedial approach resulted in the lowest pooled accuracy rates, 85% (95% CI 68-100%), 67% (95% CI 43-91%) and 72% (95% CI 65-78%), respectively.

CONCLUSIONS

The superolateral approach was investigated most and resulted in the highest pooled accuracy rate of 91% (95% CI 84-99%). Nevertheless, this approach still results in a substantial amount of extra-articular needle placements. Guidance of intra-articular needle placements by imaging techniques may enhance the accuracy. The costs and extra time associated with these techniques should be taken into consideration.

US-guided injection of the upper and lower extremity joints

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.

Combined pre-injection wrist and ankle MRI protocol and steroid joint injections in juvenile idiopathic arthritis

Precise localization of affected compartments of the wrist and ankle in children with an established diagnosis of juvenile idiopathic arthritis (JIA) is clinically challenging. The purpose of this paper is to describe our experience utilizing a pre-injection MRI protocol of the wrist and ankle for localizing disease activity followed by fluoroscopically guided joint injections in children with JIA.

Magnetic resonance-guided interventions of large and small joints

Magnetic resonance (MR)-guided interventions of large and small joints are feasible and safe procedures offering several advantages compared with standard guiding techniques. Nevertheless, MR-guided interventions are not routinely performed in daily practice apart from a few centers. Accurate injections are crucial for clinical outcome in diagnostic arthrography as well as therapeutic joint injections. In particular, palpatory joint puncture was shown to be inaccurate or uncertain in a substantial percentage of injections of the shoulder, the hip, and the knee. Magnetic resonance imaging offers respective merits of a cross-sectional technique with high soft-tissue contrast. Exact depiction of structures, which should be preserved, such as the labrum, should be aimed for. Areas with complex anatomy can be approached by adapting the right imaging plane(s) because of multiplanar capacity. Lack of ionizing radiation for patients is of growing interest particularly in young patients with repeated interventions. Magnetic resonance guidance alone allows an "all-in-one" MR arthrography combining precise targeting with high-field-strength imaging. Modern short-bore and open-bore high-field-strength systems offer a good comfort for patients as well as clinicians and enhance patient positioning options such as supine or prone position. Thus, a tailored approach such as a posterior technique for suspected anterior lesions in shoulder MR arthrography is possible.In this article, we describe the advantages and limitations of MR guidance in joint interventions with focus on shoulder and hip interventions. We review the requirements for needle material and MR sequences, discuss several different techniques developed to date, and present current results in clinical outcome.

Diagnostic and therapeutic joint injections

Joint injection is a useful tool in the diagnosis of intra-articular pathology that may improve diagnostic performance of computed tomography (CT) and magnetic resonance (MR) imaging. Historically, conventional arthrography under fluoroscopy was the first method to be used to image indirectly the intra-articular soft tissues, but with the advent of CT, CT arthrography offered better soft tissue depiction. The development of conventional MR allowed even better visualization of soft tissues, and in the early 1990s, MR arthrography surpassed CT arthrography in popularity. Joint injections may also be performed for therapeutic reasons with different drugs, such as corticosteroids, anesthetics, or hyaluronic acid, which have been shown to provide pain relief in various circumstances. In this article, the technical principles for joint injection of the shoulder, knee, elbow, hip, ankle, and wrist, used for therapeutic or diagnostic reasons, are discussed. Indications, expected benefits, and risks are also analyzed.

CT-guided sternoclavicular joint injections: description of the procedure, reliability of imaging diagnosis, and short-term patient responses

OBJECTIVE

The purpose of this study was to evaluate pain relief 20 to 30 minutes after diagnostic or therapeutic injections into the sternoclavicular joint and to compare patient outcomes based on the CT diagnosis.

MATERIALS AND METHODS

Informed consent was obtained from each patient. Ethics approval was not required. Fifty patients who had CT-guided injections of corticosteroid and local anesthetic into their sternoclavicular joints were included in the study. Preinjection and 20- to 30-minute postinjection visual analog scale data were recorded and compared with the imaging findings agreed by consensus. Kappa statistics were calculated for the reliability of imaging diagnosis. The percentage of patients improving after joint injection was calculated, and the risk ratio comparing the response of patients with osteoarthritis to those without osteoarthritis was completed. The correlation between the severity of each patient's osteoarthritis and the pain response was calculated using Spearman's correlation coefficient.

RESULTS

Sixty-six percent of the patients reported clinically significant pain reduction at between 20 and 30 minutes after injection. The proportion of patients with osteoarthritis who had a clinically significant response was 67% compared with 64% for patients who did not have osteoarthritis. This difference was not statistically or clinically significant. There was no correlation between the severity of osteoarthritis and the amount of pain reduction (r = 0.03). The reliability of imaging diagnosis was substantial.

CONCLUSION

Two thirds of patients having sternoclavicular joint injections of corticosteroids and local anesthetics report clinically significant improvement regardless of the abnormalities detected on their CT images.

Adverse events from diagnostic and therapeutic joint injections: a literature review

This review article classifies the various adverse reactions arising from intra-articular injections by severity, diagnostic category, and whether they are due to corticosteroid, local anesthetic or viscosupplementation injections. Life-threatening and serious adverse events from intra-articular injections are rare and range from local complications to systemic afflictions. Measures to reduce the likelihood of an adverse event occurring are outlined and patients with significant features in their clinical histories, predisposing them to adverse events, are highlighted.