Ultrasound-guided injections and aspirations of the extremities

Proximal Tibiofibular Joint Dysfunction as a Cause of Persistent Knee Pain After Total Knee Arthroplasty: A Case Series and Literature Review

Total knee arthroplasty (TKA) is a common procedure for end-stage osteoarthritis of the tibiofemoral and patellafemoral joints. Despite a good outcome in many patients, persistent knee pain after TKA poses a significant challenge. Proximal tibiofibular joint (PTFJ) osteoarthritis has been seen as a rare cause of such pain. In this case series, we share our experience diagnosing PTFJ dysfunction and managing it with intra-articular ultrasound-guided injections. We demonstrate that PTFJ arthropathy may be a more common cause of chronic post-TKA pain than generally believed.

Fluoroscopically-guided therapeutic injection of the proximal tibiofibular joint in a patient with lateral knee pain

Proximal tibiofibular joint (PTFJ) pathology is an uncommon but perhaps underappreciated cause of lateral knee pain. While imaging guided therapeutic injections for diagnosis and management of joint related symptoms are now commonplace and numerous techniques for accessing most joints in the body have been documented, a technique for fluoroscopically guided injection of the PTFJ has not been yet described in the literature. We present a case of an adult patient who presented with lateral knee pain refractory to conservative management who opted for a fluoroscopically-guided therapeutic injection of her PTFJ.

Ultrasound-Guided Hydraulic Release Associated With Corticosteroids in Radial Tunnel Syndrome: Description of Technique and Preliminary Clinical Results

The aim of this study was to describe a perineural ultrasound-guided infiltration technique for management of radial tunnel syndrome and to report its preliminary results in 54 patients. A mixture of a saline solution, a local anesthetic, and a corticosteroid solution was infiltrated in the perineural region at the arcade of Frohse. Pain was reported in 100% of patients before the procedure versus 1.9% after the procedure. Scratch collapse and Cozen test results were positive in 98.1% and 66.7% of patients before infiltration, respectively, versus 5.6% and 9.2% after infiltration. All variables had statistically significant differences between preprocedure and postprocedure evaluations (P < .01).

A Vascular Obstacle in Ultrasound-Guided Hip Joint Injection

Background:

We evaluated the risk of lateral circumflex femoral artery (LCFA) injury during ultrasound-guided intra-articular hip injections.

Methods:

This study was divided into three parts. (1) Four ultrasound-guided hip injections were performed on human cadavers. With needles in place, tissues were dissected to expose the LCFA. (2) Ultrasound-trained rheumatologists marked a planned needle trajectory from skin to hip joint on live human ultrasound images during an Observed Structured Clinical Examination (OSCE). Doppler was subsequently activated to locate the LCFA, and the distance between trajectory and arterial signal was recorded. (3) Rheumatologists certified in musculoskeletal ultrasound were surveyed about joint injection vascular complications.

Results:

(1) In one of the four cadaveric dissections, the needle made direct contact with the LCFA. (2) Of 27 OSCE participants, only two activated Doppler before marking simulated hip injection trajectories. Trajectories passed through LCFA Doppler signal in six (22%) cases. Mean minimal distance from trajectory to arterial signal was 4 mm (range, 0–11 mm). (3) Of 62 survey respondents, 24% stated that they did not use Doppler routinely. While none reported bleeding injuries with their patients, 16% knew of a hip injection-related vascular complication performed by another provider.

Conclusion:

There is a risk of LCFA injury during ultrasound-guided hip joint injection. Routine use of Doppler should be considered in standard hip injection protocols.

Ultrasound-guided musculoskeletal procedures in children

Ultrasound is an excellent tool to evaluate many pediatric musculoskeletal conditions. It may be used for both diagnosis and for guidance for therapeutic procedures. With US, the radiologist can readily evaluate the contralateral side for comparison. No sedation is typically required and ionizing radiation is avoided. Real-time information is obtained with US and the portability of US allows for the performance of bedside interventions in children who cannot be transported or are clinically unstable. Limitations of US compared with MRI and CT include limited field of view, inability to evaluate the bone marrow and user dependence of image and exam quality. In this article, we discuss common US-guided musculoskeletal procedures in children, including hip aspiration, joint injection, soft-tissue biopsy and foreign body removal.

Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks

Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.

[Ultrasound-guided joint injections in patients with rheumatic diseases]

Joint and soft tissue injections are routinely performed in daily rheumatology practice to establish the diagnosis or as part of the treatment in patients suffering from rheumatic diseases. Consequently, joint injections have been included in the rheumatology further training curriculum. Despite numerous studies demonstrating a poor accuracy and outcome of joint injections guided only by clinical examination, most of the injection procedures are still performed in a "blind" fashion based on clinical judgment. Ultrasound has evolved as an established imaging method in rheumatology within the past decade and is considered the preferred imaging modality for joint interventions due to its availability and lack of radiation exposure. In this article the indications and important aspects of the practical management of ultrasound-guided injections performed in daily rheumatology practice are summarized.

Sonographically guided therapeutic injection for primary medial (tibial) collateral bursitis

The purpose of this article is to describe a sonographically guided technique to perform therapeutic injection into the medial collateral ligament bursa. Scans are performed using a high-frequency linear transducer with the scan plane corresponding to the anatomic coronal plane. The transducer is positioned along the medial aspect of the knee; a 25-gauge needle is placed along the inferior border of the bursa; and a standardized therapeutic mixture (anesthetic and long-active corticosteroid) is injected. Distention of the bursa is the determining factor for a successful injection. Sonography allows confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes.

Sonographically guided proximal tibiofibular joint injection: technique and accuracy

OBJECTIVE

The purpose of this investigation was to describe a technique for sonographically guided proximal tibiofibular joint (PTFJ) injections and compare its accuracy with that of palpation guided injections in a cadaveric model.

METHODS

A single experienced operator completed 12 sonographically guided and 12 palpation guided PTFJ injections in unembalmed cadavers. The injection order was randomized, and all injections were completed with diluted colored latex. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the PTFJ), accurate with overflow (within the PTFJ but also in other regions), or inaccurate (no latex in the joint). For statistical analysis, all injections placing latex within the PTFJ were considered "accurate," whereas "inaccurate" injections resulted in no PTFJ latex.

RESULTS

All 12 sonographically guided PTFJ injections accurately placed latex into the PTFJ (100% accuracy), whereas only 7 of 12 palpation guided injections (58%) placed latex within the PTFJ (P = .01). All 5 inaccurate palpation guided injections were superficial and inferior to the PTFJ. Four of 12 accurate sonographically guided PTFJ injections (33%) showed some overflow into the adjacent anterior musculature, whereas 5 of the accurate palpation guided injections (42%) resulted in overflow into the anterior musculature (1), knee joint (2), or both (2).

CONCLUSIONS

This cadaveric investigation suggests that sonographic guidance can be used to inject the PTFJ with a high degree of accuracy and should be considered superior to palpation guidance. Clinicians should consider using sonographic guidance to inject the PTFJ for diagnostic or therapeutic purposes when clinically indicated.

Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines

OBJECTIVE

The purpose of this study was to compare infection rates of peripheral intravenous (IV) lines placed under ultrasound guidance with traditionally placed IV lines.

METHODS

We conducted a retrospective review of emergency department (ED) and hospital records of adult patients who had a peripheral IV line placed in the ED and were admitted to the hospital over a 1-year period. This study took place at a level I academic urban ED with an annual census of 75,000. All admitted patients with a peripheral IV placed under ultrasound guidance in the ED were identified. Control patients had a traditional landmark approach. Emergency department nurses followed standard aseptic precautions when inserting both ultrasound-guided as well as traditionally placed IV lines. Researchers reviewed all parts of the medical record, including ED and inpatient notes. Descriptive statistics and chi(2) and Fisher exact tests were used in data evaluation.

RESULTS

A total of 402 patients who had peripheral IV lines placed under ultrasound guidance were compared with 402 matched control patients. In the ultrasound-guided IV group, the mean time between insertion to catheter removal was 2.6 days compared with 2.4 days in the traditional group (P = .03). There were 2 documented infections in the ultrasound group and 3 in the traditional group, yielding infection rates of 5.2 per 1000 in the ultrasound-guided IV group and 7.8 per 1000 in the traditional approach group. There was no statistically significant difference between infection rates in the two groups (P = .68).

CONCLUSIONS

Both traditional and ultrasound-guided approaches had low infection rates, suggesting that there is no increased risk of infection with ultrasound guidance for peripheral IV lines.

Accuracy of sonographically guided posterior subtalar joint injections: comparison of 3 techniques

OBJECTIVE

The primary purpose of this investigation was to determine the accuracy of 3 different sonographically guided posterior subtalar joint (PSTJ) injection techniques in an unembalmed cadaveric model.

METHODS

A single experienced examiner injected the PSTJs of 12 unembalmed cadaveric ankle-foot specimens using the anterolateral, posterolateral, and posteromedial approaches. The injection order for each specimen was randomized, and each technique was completed with a different-color diluted latex solution. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the PSTJ), accurate with overflow (within the PSTJ but also in other regions), or inaccurate (no latex in the joint).

RESULTS

All 3 sonographically guided PSTJ injection approaches accurately placed latex into the PSTJ (100% accuracy). Latex was also found in adjacent regions in 19.4% (7 of 36) of injections: 8.3% (3 of 36) within the tibiotalar joint, 8.3% (3 of 36) in the peroneal (fibularis) tendon sheath, and 2.8% (1 of 36) in the flexor hallucis longus tendon sheath. The anterolateral approach placed latex outside the PSTJ 25% of the time (3 of 12 injections: 1 tibiotalar and 2 peroneal [fibularis] sheath), the posterolateral approach 25% of the time (3 of 12 injections: 1 tibiotalar, 1 peroneal [fibularis] sheath, and 1 flexor hallucis longus tendon sheath), and the posteromedial approach 8.3% of the time (1 tibiotalar).

CONCLUSIONS

This cadaveric investigation suggests that all 3 sonographically guided PSTJ techniques may be used to access the PSTJ with a high degree of accuracy. Clinicians should consider sonographically guided PSTJ injections as a favorable alternative to fluoroscopy and computed tomographic guidance when diagnostic or therapeutic image-guided PSTJ injections are indicated.

US guided injections in arthritis

US guided procedures for diagnosis or treatment of different forms of arthritis are becoming more and more important. This review describes general considerations for fluid aspiration, articular or periarticular injections and biopsies by US guidance according to the recent literature. Guidelines regarding instrumentation, different techniques, pre- and postprocedural care as well as complications are outlined and in the second part a more detailed overview of different interventions in joints, tendons and other periarticular regions (nerves, bursae, etc.) is included. Furthermore, some newer, more sophisticated techniques are briefly discussed.

Ultrasound-guided therapeutic procedures in the musculoskeletal system

Ultrasound allows the exploration of most of the musculoskeletal system, including lytic bone lesions. Its flexibility, availability, and low cost make it the best tool to guide interventional therapeutic procedures in any musculoskeletal system lesion visible on ultrasound. These techniques include drainages of abscesses, bursitis, hematomas or muscular strains, treatment of cystic lesions (ganglions, Baker's cysts), arthrocentesis, injection of substances in joints and soft tissues, and aspiration of calcific tendinitis. Although the puncture of joints for arthrocentesis and injection of substances are performed by clinicians using palpation, the use of ultrasound guidance improves the effectiveness of the technique especially for small or poorly accessible lesions and joints and for obese patients. Drainage can be performed using catheters or needles and can avoid a more aggressive approach most of the time. Intracavitary urokinase helps when the aim is to drain clotted hematomas or fibrinous collections. Injection of corticoids is useful in the treatment of ganglia, Baker's cysts, tendinitis, and noninfected arthritis. Calcific tendinitis of the shoulder can be effectively treated using percutaneous "lavage" with lidocaine. Calcifications usually disappear and symptoms improve in nearly 90% of the cases within a year. Most of these techniques are low cost and require only a moderate skill. Ultrasound-guided procedures are useful tools to effectively treat some diseases of the musculoskeletal system and should be routine in any imaging department.

Placement of intra-articular injection verified by the backflow technique

OBJECTIVE

To develop and to assess a simple, inexpensive method for ascertaining, without any imaging procedure, the intra-articular placement of the needle in the knee for intra-articular injections.

METHODS

Outpatients referred for intra-articular treatment with "dry" symptomatic knee osteoarthritis were included in this prospective study. "Dry" knee disease was defined as a knee without any clinically detectable effusion. Once intra-articular positioning of the needle considered adequate using the backflow technique, contrast solution was injected using the same needle without changing its position and immediately afterwards lateral and anterior-posterior X-rays were taken to assess the needle position.

RESULTS

Of the 32 of 33 cases with obtained backflow, the needle was correctly placed in all cases. In the remaining case, the needle was extra-articularly positioned. The concordance between the two techniques using the Cohen's Kappa was 1 [CI 95%: 0.22-1].

CONCLUSION

The backflow technique allows to accurate the intra-articular placement of the needle for "dry" knee joints injection. This technique can be proposed as a learning tool as well as a daily practice technique to ascertaining intra-articular knee injections without using fluoroscopy with injection of contrast material. Further studies are needed to assess the technique for other joint injections.