Upper Limb Interventions

Updates in Ultrasound in Rheumatology

BACKGROUND

The purpose of the authors' narrative review was to outline the current literature regarding the use of ultrasound in main rheumatic disorders and summarize the updates, specifically about rheumatoid arthritis, psoriatic arthritis, and crystal-induced arthropathies.

METHODS

The authors searched on PubMed for articles discussing the major updates regarding the role of ultrasound in the previously mentioned rheumatic conditions.

RESULTS

The authors have provided the updated definitions, new criteria, and diagnostic scores.

CONCLUSIONS

In rheumatology's dynamic landscape, this review provides valuable insights for researchers and clinicians on ultrasound's role in improving patient care and outcomes in rheumatic diseases.

US-guided percutaneous irrigation of extra-shoulder calcific tendinitis

OBJECTIVES

To investigate the efficacy and safety of ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) applied out of the shoulder, comparing its effectiveness to US-PICT of the rotator cuff.

METHODS

Patients subjected to US-PICT for extra-shoulder calcific tendinitis (Case Group) were compared to those subjected to US-PICT of the rotator cuff (Control Group). We had pre-procedure Visual Analogue Scale (VAS) pain score, 1- and 3-month VAS of patients of the Case Group, pre-procedure and 3-month VAS of patients of the Control Group.

RESULTS

The Case Group consisted of 41 patients (27 women; mean age: 45 ± 9years): 26 gluteus medius, 5 patellar tendon, 3 rectus femoris, 2 gluteus maximus, 2 common extensor tendon, 1 extensor carpi radialis longus, 1 pes anserinus, and 1 peroneus longus. The Control Group included 41 patients (27 women; mean age: 47 ± 11 years). The mean pre-procedure VAS of the Case Group was 8.8 ± 0.7 with a significant (P < .001) drop at 1 month (4.5 ± 0.6) and 3 months (3.6 ± 0.6). The mean pre-procedure VAS of the Control Group was 8 ± 1.4 and dropped to 3.1 ± 1.6 after 3 months (P < .001). Post-treatment VAS at 3 months was not significantly different between two Groups (P = 0.134). Similarly, the decrease of VAS from baseline to 3 months was not significantly different between the two Groups (P = 0.264).

CONCLUSIONS

US-PICT is a safe and effective procedure that can be used out of the shoulder.

ADVANCES IN KNOWLEDGE

This study demonstrated the safety and effectiveness of US-PICT as a valuable therapeutic option for extra-shoulder calcific tendinitis, with similar clinical outcome to the same procedure performed in the rotator cuff. The technique must be adapted in some deeply located calcifications by means of the use of different needles and by thoroughly planning the access point for the procedure.

Ultrasound-guided injection of the elbow: Cadaveric description for the proximal to distal approach

BACKGROUND

Ultrasound (US) guided intra-articular elbow injections are commonly performed in clinical practice.

OBJECTIVE

To describe a proximal to distal approach for US-guided intra-articular elbow injection.

DESIGN

Cadaveric study.

SETTINGS

Academic institution.

METHODS

Both elbows of a single cadaver were injected with green-colored water-diluted latex dye using the US-guided proximal to distal approach. In the left elbow, the needle was kept in situ; in the right elbow, the needle was removed. Subsequently, a layer-by-layer anatomical dissection was performed in both elbows.

MAIN OUTCOME MEASURES

Presence and distribution of the latex dye and location of the needle tip within the elbow joint capsule.

RESULTS

Anatomical dissection of both elbows confirmed the correct intra-articular position of the needle tip in the left elbow as well as correct placement of the latex dye bilaterally. During layer-by-layer dissection of the left elbow, the position of the radial nerve was observed anterior to the needle.

CONCLUSIONS

This cadaveric observation demonstrated that the US-guided proximal to distal approach is a convenient technique to access the elbow joint. Compared to the previously described techniques, the in-plane, proximal to distal approach may provide excellent needle visibility during the entire procedure, precisely targeting the articular space. The preliminary data need to be validated in additional clinical studies.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Imaging-Guided Musculoskeletal Interventions in the Lower Limb

Imaging guidance is essential for musculoskeletal interventional procedures performed in the lower limb. A strong evidence supports the use of imaging guidance to improve safety, accuracy, and effectiveness of these interventions. Joints, tendons, bursae, and nerves can be effectively approached especially with ultrasound-guided injections. Here, we discuss evidence and technique of the most common image-guided musculoskeletal interventional procedures in the lower limb.

Ultrasound-guided Musculoskeletal Interventional Procedures Around the Hip: A Practical Guide

Several studies have shown that ultrasound guidance may contribute to improved safety, effectiveness and accuracy of musculoskeletal interventional procedures performed around the hip if compared to those performed with a landmark-guided technique. Different approaches and injectates can be used for treating hip musculoskeletal disorders. These procedures may involve injections in the hip joint, periarticular bursae, tendons, and peripheral nerves. Intra-articular hip injections are mostly used as a conservative approach for treating patients affected by hip osteoarthritis. Ultrasound-guided injection of the iliopsoas bursa is performed in patients with bursitis and/or tendinopathy, to treat those with painful prosthesis due to iliopsoas impingement, or when the lidocaine test is indicated to identify the iliopsoas as a source of pain. Ultrasound-guided interventions are routinely used in patients with greater trochanteric pain syndrome having as target the gluteus medius/minimus tendons and/or the trochanteric bursae. Ultrasound-guided fenestration and platelet-rich plasma injection are applied in patients with hamstring tendinopathy with good clinical outcomes. Last but not least, ultrasound-guided perineural injections can be used for peripheral neuropathies or blocks of the sciatic, lateral femoral cutaneous, and pudendal nerves. In this paper, we discuss the evidence and technical tips for musculoskeletal interventional procedures performed around the hip, highlighting the added value of ultrasound as an imaging guidance modality.

Current concepts in the diagnosis and treatment of adhesive capsulitis: role of diagnostic imaging and ultrasound-guided interventional procedures

Adhesive capsulitis is a common cause of painful shoulder, characterized by pain and restricted range of motion of the glenohumeral joint. With a well-known clinical presentation, and an increasing understanding of its clinical and radiologic features, early diagnosis of adhesive capsulitis is becoming a reality. Although often treated conservatively, for refractory cases arthroscopic release and open capsulotomy have been the only therapeutic option for a long time. Therefore, in the last years, a particular effort was put into the development of novel minimal-invasive techniques capable of pain relief and functional range improvement of the glenohumeral joint. The purpose of this literature review is to report the main updates on diagnosis and treatment for adhesive capsulitis with a focus on imaging diagnosis techniques and novel minimally invasive ultrasound-guided treatments. Results showed that ultrasound-guided procedures come with a high success rate in terms of pain reduction and improved range of motion, thus making the ultrasound a unique tool capable of giving the operator real-time diagnostic information confirming the clinical suspicion, and subsequently performing an interventional procedure.

Ultrasound-Guided Musculoskeletal Injections

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

Ultrasound-guided musculoskeletal interventional procedures around the shoulder

Ultrasound is a fast, accessible, reliable, and radiation-free imaging modality routinely used to assess the soft tissues around the shoulder. It enables to identify a wide range of pathological conditions. Furthermore, most ultrasound-guided musculoskeletal interventional procedures around the shoulder produce better results in terms of accuracy and clinical efficacy than those performed in a blinded fashion. Indeed, intra-articular and peri-articular interventional procedures can be easily performed under continuous ultrasound monitoring to ensure the correct position of the needle and to deliver the medication to a specific target. Several technical approaches and medications can be used to treat different causes of painful shoulder. Intra-articular injections are applied to treat acromioclavicular osteoarthritis as well as glenohumeral joint osteoarthritis and adhesive capsulitis. Subacromial-subdeltoid bursitis, either presenting as a primary inflammatory condition or secondary to rotator cuff disorders, can be easily approached using ultrasound guidance to aspirate synovial effusion and to inject medications. Ultrasound-guided percutaneous irrigation is a well-established technique increasingly applied to treat patients with rotator cuff calcific tendinopathy. Also, degenerative rotator cuff tendinopathy can be conservatively treated by image-guided interventions, specifically with needling under ultrasound guidance that can be associated with injections of platelet-rich plasma. Lastly, periarticular peripheral nerve block can be quickly and safely performed under ultrasound guidance, particularly in conditions involving the suprascapular nerve in the setting of pre-operative analgesia or pain treatment in glenohumeral osteoarthritis and adhesive capsulitis. In this article, the most common ultrasound-guided procedures around the shoulder have been reviewed to discuss indications and techniques.

Ultrasound-guided musculoskeletal interventional procedures around the elbow, hand and wrist excluding carpal tunnel procedures

Ultrasound is a fast, reliable and radiation-free method for the assessment of a wide range of pathological conditions, as well as for the guidance of percutaneous interventional procedures around the elbow, hand and wrist. Intraarticular and periarticular interventional procedures can be easily performed under continuous ultrasound monitoring to ensure correct needle positioning and medication delivery to a specific target. The most common ultrasound-guided procedures performed around the elbow, wrist, and hand are described in this review, excluding carpal tunnel procedures. Specifically, elbow steroid injections are performed in patients with inflammatory disorders, while hyaluronic acid can be administered in case of osteoarthritis. Septic olecranon bursitis requires percutaneous drainage for diagnosis and appropriate treatment. Dry needling and injection of regenerative medications, such as blood derivatives, are among the treatment options for lateral epicondylosis. Steroid injections are performed to give symptom relief in patients with ulnar neuropathy at the elbow. Hand and wrist steroid injections are performed in case of osteoarthritis, subsequently followed by hyaluronic acid injections, and in inflammatory disorders. Wrist ganglia can be safely aspirated and injected with steroids under ultrasound guidance. De Quervain’s tenosynovitis and trigger finger are chronic tenosynovitides of the wrist and digits, respectively, which can be treated with steroid injections, subsequently followed by hyaluronic acid injections. In conclusion, proper knowledge of the musculoskeletal disorders around the elbow, hand and wrist, as well as US-guided treatment options and operator training, are prerequisites to achieve good outcomes.

Pulley, Flexor, and Extensor Tendon Injuries of the Hand

Tendon injuries represent the second most common injury of the hand (after fractures) and are a common scanning indication in radiology. Pulley injuries are very frequent in rock climbers with the A2 pulley the most commonly affected. Tendon and pulley injuries can be reliably evaluated using ultrasound (US) and magnetic resonance imaging (MRI). US can be postulated as a first-line imaging modality, allowing dynamic examination. MRI is essential for cases with ongoing diagnostic doubt post-US and also for preoperative pulley reconstruction assessment.

Ultrasound Imaging and Guidance in Common Wrist/Hand Pathologies

ABSTRACT

Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). Although most of the anatomical structures are quite superficial and easily evaluated during physical examination, for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis, and the radiocarpal joint arthritis. In addition, evidence from the literature supporting the rationale why ultrasound guidance is henceforth unconditional in musculoskeletal practice is also exemplified.

Imaging of calcific tendinopathy around the shoulder: usual and unusual presentations and common pitfalls

Rotator cuff calcific tendinopathy (RCCT) is a very common condition, characterized by calcium deposition over fibrocartilaginous metaplasia of tenocytes, mainly occurring in the supraspinatus tendon. RCCT has a typical imaging presentation: in most cases, calcific deposits appear as a dense opacity around the humeral head on conventional radiography, as hyperechoic foci with or without acoustic shadow at ultrasound and as a signal void at magnetic resonance imaging. However, radiologists have to keep in mind the possible unusual presentations of RCCT and the key imaging features to correctly differentiate RCCT from other RC conditions, such as calcific enthesopathy or RC tears. Other presentations of RCCT to be considered are intrabursal, intraosseous, and intramuscular migration of calcific deposits that may mimic infectious processes or malignancies. While intrabursal and intraosseous migration are quite common, intramuscular migration is an unusual evolution of RCCT. It is important also to know atypical regions affected by calcific tendinopathy as biceps brachii, pectoralis major, and deltoid tendons. Unusual presentations of RCCT may lead to diagnostic challenge and mistakes. The aim of this review is to illustrate the usual and unusual imaging findings of RCCT that radiologists should know to reach the correct diagnosis and to exclude other entities with the purpose of preventing further unnecessary imaging examinations or interventional procedures.

Post-surgical Achilles calcific tendinopathy treated with ultrasound-guided percutaneous irrigation

Calcific tendinopathy typically affects the shoulder rotator cuff tendons. Its management includes shock wave therapy and US-guided percutaneous irrigation, with surgery being less and less used. Extra-shoulder calcific tendinopathy is relatively infrequent and typically affects the hip. While the diagnostic techniques and the treatment options for shoulder calcific tendinopathy have been extensively described, there are only anecdotic reports on the other sites. In this paper, we have reported an unusual case of non-insertional Achilles calcific tendinopathy which occurred many years after Achilles surgical repair. This condition, which presented similar appearance to that of the rotator cuff calcific tendinopathy, is totally different from the well-known and more common insertional calcific Achilles tendinopathy in terms of pathophysiological, imaging, and clinical findings. Further, we have shown that US-guided percutaneous irrigation might be a safe, technically feasible, mini-invasive, and effective treatment also for Achilles calcific tendinopathy.

Ultrasound-Guided Percutaneous Tenotomy of the Long Head of Biceps Tendon in Patients with Symptomatic Complete Rotator Cuff Tear: In Vivo Non-contRolled Prospective Study

Background: We prospectively tested technical feasibility and clinical outcome of percutaneous ultrasound-guided tenotomy of long head of biceps tendon (LHBT). Methods: We included 11 patients (6 women; age: 73 ± 8.6 years) with symptomatic full-thickness rotator cuff tear and intact LHBT, in whom surgical repair was not possible/refused. After ultrasound-guided injection of local anesthetic, the LHBT was cut with a scalpel under continuous ultrasound monitoring until it became no longer visible. Pain was recorded before and at least six months after procedure. An eight-item questionnaire was administered to patients at follow-up. Results: A median of 4 tendon cuts were needed to ensure complete tenotomy. Mean procedure duration was 65 ± 5.7 s. Mean length of skin incision was 5.8 ± 0.6 mm. Pre-tenotomy VAS score was 8.2 ± 0.7, post-tenotomy VAS was 2.8 ± 0.6 (p < 0.001). At follow-up, 5/11 patients were very satisfied, 5/11 satisfied and 1/11 neutral. One patient experienced cramping and very minimal pain in the biceps. Six patients had still moderate shoulder pain, 1/11 minimal pain, 2/11 very minimal pain, while 2/11 had no pain. No patients had weakness in elbow flexion nor limits of daily activities due to LHBT. One patient showed Popeye deformity. All patients would undergo ultrasound-guided tenotomy again. Conclusion: ultrasound-guided percutaneous LHBT tenotomy is technically feasible and effective.

Ultrasound of iliotibial band syndrome

Iliotibial band syndrome or friction syndrome is an overuse disorder of the lateral knee. It is commonly reported in athletes, such as runners and cyclists, and refers to pain related to physical activity. The diagnosis is based on clinical history and physical assessment. Imaging, including ultrasound, is mainly performed in recurrent or refractory cases. The purpose of this paper is to review the etiology, diagnosis, and therapy of iliotibial band syndrome with a focus on ultrasound imaging and ultrasound-guided treatment. Ultrasound findings include soft-tissue edematous swelling or discrete fluid collection, suggestive of bursitis, between the iliotibial band and the lateral femoral epicondyle. The thickening of the iliotibial band has been inconsistently reported. Treatment varies according to the disease phase and, in the acute phase, consists of rest, physical therapy, and anti-inflammatory medications. Ultrasound-guided local steroid injections are effective in relieving symptoms.

Ultrasound-Guided Percutaneous Irrigation of Rotator Cuff Calcific Tendinopathy (US-PICT): Patient Experience

Purpose

To assess patients' experience of ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinopathy (US-PICT).

Methods

Ninety-one patients (58 females; mean age: 50.5 ± 8.3 years) treated by US-PICT (local anesthesia, single-needle lavage, and intrabursal steroid injection) answered to a list of questions regarding their experience of the procedure before treatment, immediately after treatment, and three months later. The Borg CR10 scale was used to evaluate perceived pain, discomfort during anesthetic injection, and anxiety. The Wilcoxon, Spearman's rho, linear regression, and chi-square statistics were used.

Results

81/91 patients complained mild discomfort during the injection of anesthetics (2, 1-2). Pain scores during US-PICT were very low (0, 0-1), with 70% patients having not experienced pain. After treatment, we found a significant reduction of pain (before: 8, 7-8; 3-month: 3, 1-6; p < .001) and anxiety (before: 5, 2-7; during treatment: 2, 1-7; p = 0.010), with high overall satisfaction (immediately after: 10, 9-10; 3-month: 9, 7-10) and confidence in the possibility of recovery (immediately after: 9, 8-10; 3-month: 10, 8-10), respectively. Treatments performed before US-PICT were not statistically associated with pain relief (p = 0.389) and clinical improvement (p = 0.937). We found a correlation between satisfaction immediately postprocedure and confidence in the possibility of recovery (p = 0.002) and between satisfaction three months after treatment and clinical improvement (p < 0.001) and patients' reminds about the description of the procedure (p = 0.005) and of the potential complications (p = 0.035).

Conclusions

US-PICT is a mildly painful, comfortable, and well-tolerated procedure, regardless of any previous treatments. Patients' satisfaction is correlated with clinical benefit and full explanation of the procedure and its complications.

US-guided percutaneous irrigation of calcific tendinopathy of the rotator cuff in patients with or without previous external shockwave therapy

OBJECTIVES

To compare the outcome of US-guided percutaneous irrigation of calcific tendinopathy (US-PICT) of the rotator cuff in patients with or without previous external shockwave therapy (ESWT).

METHODS

We analyzed all patients treated with US-PICT from March 1, 2016, to October 1, 2019, with shoulder pain refractory to conservative management for rotator cuff calcific tendinopathy, diagnosed with ultrasound. Each patient was examined using the Constant-Murley Score (CMS) questionnaire (score 0-100) before and after treatment. We tested CMS differences using the Mann-Whitney U (Wilcoxon rank-sum) test in the two groups. US-PICT was performed placing two or multiple 14G needles, according to the calcification size, inserted under US guidance to create a circuit of irrigation in the calcified tendon. NaCl solution at 38 °C was then injected from the entry needle in a variable amount to hydrate and fragment the calcification, finally allowing for its expulsion through the exit needle. All patients also received an intrabursal steroid injection.

RESULTS

From 2016 to 2019, 72 US-PICT treatments were performed on 70 patients (females = 46; males = 26) with a mean age of 49.7 years (SD = 8.7. Thirty-three (47%) underwent previous ESWT, while thirty-seven (53%) had no previous treatments. No treatment-related complications were observed. Follow-up was averagely 14.4 months (median = 11.6, SD = 11.9, range 1-45); 37 patients had a follow-up shorter than 12 months (1-11.6); 35 patients were visited after more than 1 year (12.2-45.6, Table W). Before treatment, the mean CMS was 35 (SD = 21); after treatment, it reached 75.4, with an average CMS improvement of 40.3 points (SD = 23.7, p < 0.001). The comparison of improvement between the ESWT and non-ESWT group yielded no significant difference (p = 0.3).

CONCLUSIONS

US-PICT of the rotator cuff is an effective procedure to reduce shoulder pain and increase mobility in patients with calcific tendinopathy, both in short- and long-term time intervals. Previous unsuccessful ESWT does not affect the outcome of US-PICT.

Posterior Shoulder Instability: What to Look for

Posterior shoulder instability is often hard to diagnose with clinical examination. Patients generally present with vague pain, weakness, and/or joint clicking but less frequently complaining of frank sensation of instability. Imaging examinations, especially MR imaging and magnetic resonance arthrography, have a pivotal role in the identification and management of this condition. This review describes the pathologic micro/macrotraumatic magnetic resonance features of posterior shoulder instability as well as the underlying joint abnormalities predisposing to this condition, including developmental anomalies of the glenoid fossa, humeral head, posterior labrum, and capsular and ligamentous structures.