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Cimpeanu R, Castrejón-Pita AA, Lim LN, Vatish M, Georgiou EX. A new flow-based design for double-lumen needles. J Biomech 2023; 160:111832. [PMID: 37837837 DOI: 10.1016/j.jbiomech.2023.111832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/28/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
Oocyte retrieval forms a crucial part of in vitro fertilisation treatment and its ultimate outcome. Standard double-lumen needles, which include a sequence of aspiration and flushing steps, are characterised by a similar success rate to single-lumen needles, despite their increased cost. A novel hydrodynamics-based needle called the OxIVF needle is proposed here, which is geared towards the generation of an internal flow field within the full follicular volume via laterally, rather than frontally, oriented flushing, leading to successful retrievals with no additional stress on the oocyte. A two-dimensional digital twin of the follicular environment is created and tested via multi-phase flow direct numerical simulation. Oocyte initial location within the follicle is varied, while quantities of interest such as velocity magnitude and vorticity are measured with a high level of precision. This provides insight into the overall fluid motion, as well as the trajectory and stresses experienced by the oocyte. A comparative benchmark set of tests indicated a higher success rate of the OxIVF needle of up to 100%, marking a significant improvement over the traditional double-lumen design whose success rate of no more than 75% was also highly dependent on the location of the needle tip inside the follicle. All forces measured during these tests showcase how the oocyte experiences stresses which are no larger than at the aspiration point, with the flow field providing a gentle steering effect towards the extraction region. Finally, the flow generation strategy maximises oocyte yield, unlocking new capabilities in both human and veterinary contexts.
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Affiliation(s)
- Radu Cimpeanu
- Mathematics Institute, University of Warwick, Coventry, CV4 7AL, United Kingdom; Mathematical Institute, University of Oxford, Oxford, OX2 6GG, United Kingdom.
| | | | - Lee Nai Lim
- Gynaecology Department, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom
| | - Manu Vatish
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford, OX3 9DU, United Kingdom
| | - Ektoras X Georgiou
- Gynaecology Department, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom
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2
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Fuentes-Braesch M, Tuijthof GJM, Emans PJ, Emanuel KS. The preferred technique for knee synovium biopsy and synovial fluid arthrocentesis. Rheumatol Int 2023; 43:1767-1779. [PMID: 36513849 DOI: 10.1007/s00296-022-05256-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022]
Abstract
For knee osteoarthritis and related conditions, analysis of biomarkers hold promise to improve early diagnosis and/or offer patient-specific treatment. To compare biomarker analyses, reliable, high-quality biopsies are needed. The aim of this work is to summarize the literature on the current best practices of biopsy of the synovium and synovial fluid arthrocentesis. Therefore, PubMed, Embase and Web of Science were systematically searched for articles that applied, demonstrated, or evaluated synovial biopsies or arthrocentesis. Expert recommendations and applications were summarized, and evidence for superiority of techniques was evaluated. Thirty-one studies were identified for inclusion. For arthrocentesis, the superolateral approach in a supine position, with a 0°-30° knee flexion was generally recommended. 18-gage needles, mechanical compression and ultrasound-guidance were found to give superior results. For blind and image-guided synovial biopsy techniques, superolateral and infrapatellar approaches were recommended. Single-handed tools were preconized, including Parker-Pearson needles and forceps. Sample quantity ranged approximately from 2 to 20. Suggestions were compiled for arthrocentesis regarding approach portal and patient position. Further evidence regarding needle size, ultrasound-guidance and mechanical compression were found. More comparative studies are needed before evidence-based protocols can be developed.
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Affiliation(s)
- Marie Fuentes-Braesch
- Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
- Department of Orthopedic Surgery, Maastricht UMC+, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Gabriëlle J M Tuijthof
- Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
| | - Pieter J Emans
- Department of Orthopedic Surgery, Maastricht UMC+, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Kaj S Emanuel
- Department of Orthopedic Surgery, Maastricht UMC+, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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3
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Korpershoek JV, Vonk LA, Filardo G, Kester EC, van Egmond N, Saris DB, Custers RJ. Effect of Autologous Conditioned Plasma Injections in Patients With Knee Osteoarthritis. Orthop J Sports Med 2023; 11:23259671231184848. [PMID: 37529531 PMCID: PMC10387782 DOI: 10.1177/23259671231184848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/13/2023] [Indexed: 08/03/2023] Open
Abstract
Background Autologous conditioned plasma (ACP) is a commercially available platelet concentrate with promising results from clinical trials. Purpose To evaluate the clinical outcome after 3 consecutive injections of ACP in patients with knee osteoarthritis (OA) and study the influence of ACP composition and different patient factors as predictors of treatment effect. Study Design Case series; Level of evidence, 4. Methods This prospective case series included 260 patients (307 knees) who received ACP treatment for knee OA. The mean patient age was 51 ± 10 years. Improvement up to 12 months' follow-up was measured using the Knee injury and Osteoarthritis Outcome Score (KOOS). ACP composition was analyzed in 100 patients. The predictive value of age, sex, history of knee trauma, Kellgren-Lawrence OA grade, body mass index, and ACP composition was evaluated using generalized estimating equations. Results The mean overall KOOS improved from 38 ± 14 at baseline to 45 ± 18 at 3 months, 45 ± 18 at 6 months, and 43 ± 18 at 12 months (all P < .05); 40% of patients achieved an improvement above the minimal clinically important difference (MCID) of 8 after 6 months and 33% after 12 months. The variation in ACP composition did not correlate with KOOS (P > .05). Older age led to a greater clinical benefit (β = 0.27; P = .05), whereas bilateral treatment predicted worse outcomes (β = -5.6; P < .05). Conclusion The improvement in KOOS after treatment with ACP did not reach the MCID in most study patients. Older age was a predictor for better outcomes. The composition of ACP varied between patients but did not predict outcomes within the evaluated range. The study findings show the limited benefit of ACP treatment for knee OA and call for caution with routine use in clinical practice.
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Affiliation(s)
| | - Lucienne A. Vonk
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Esmee C. Kester
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nienke van Egmond
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniël B.F. Saris
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Reconstructive Medicine, University of Twente, Enschede, the Netherlands
| | - Roel J.H. Custers
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
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4
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Saha P, Smith M, Hasan K. Accuracy of Intraarticular Injections: Blind vs. Image Guided Techniques-A Review of Literature. J Funct Morphol Kinesiol 2023; 8:93. [PMID: 37489306 PMCID: PMC10366715 DOI: 10.3390/jfmk8030093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/03/2023] [Accepted: 06/27/2023] [Indexed: 07/26/2023] Open
Abstract
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.
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Affiliation(s)
- Prasenjit Saha
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Matthew Smith
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Khalid Hasan
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA 23298, USA
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Guermazi A, Roemer FW, Crema MD, Jarraya M, Mobasheri A, Hayashi D. Strategic application of imaging in DMOAD clinical trials: focus on eligibility, drug delivery, and semiquantitative assessment of structural progression. Ther Adv Musculoskelet Dis 2023; 15:1759720X231165558. [PMID: 37063459 PMCID: PMC10103249 DOI: 10.1177/1759720x231165558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/02/2023] [Indexed: 04/18/2023] Open
Abstract
Despite decades of research efforts and multiple clinical trials aimed at discovering efficacious disease-modifying osteoarthritis (OA) drugs (DMOAD), we still do not have a drug that shows convincing scientific evidence to be approved as an effective DMOAD. It has been suggested these DMOAD clinical trials were in part unsuccessful since eligibility criteria and imaging-based outcome evaluation were solely based on conventional radiography. The OA research community has been aware of the limitations of conventional radiography being used as a primary imaging modality for eligibility and efficacy assessment in DMOAD trials. An imaging modality for DMOAD trials should be able to depict soft tissue and osseous pathologies that are relevant to OA disease progression and clinical manifestations of OA. Magnetic resonance imaging (MRI) fulfills these criteria and advances in technology and increasing knowledge regarding imaging outcomes likely should play a more prominent role in DMOAD clinical trials. In this perspective article, we will describe MRI-based tools and analytic methods that can be applied to DMOAD clinical trials with a particular emphasis on knee OA. MRI should be the modality of choice for eligibility screening and outcome assessment. Optimal MRI pulse sequences must be chosen to visualize specific features of OA.
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Affiliation(s)
| | - Frank W. Roemer
- Department of Radiology, Universitätsklinikum Erlangen & Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Department of Radiology, School of Medicine, Boston University, Boston, MA, USA
| | - Michel D. Crema
- Institute of Sports Imaging, Sports Medicine Department, French National Institute of Sports (INSEP), Paris, France
- Department of Radiology, School of Medicine, Boston University, Boston, MA, USA
| | - Mohamed Jarraya
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Mobasheri
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- World Health Organization Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liege, Belgium
| | - Daichi Hayashi
- Department of Radiology, Tufts Medical Center, Tufts Medicine, Boston, MA, USA
- Department of Radiology, School of Medicine, Boston University, Boston, MA, USA
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6
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Kon E, Boffa A, Andriolo L, Di Martino A, Di Matteo B, Magarelli N, Trenti N, Zaffagnini S, Filardo G. Combined subchondral and intra-articular injections of bone marrow aspirate concentrate provide stable results up to 24 months. Knee Surg Sports Traumatol Arthrosc 2022; 31:2511-2517. [PMID: 36326876 DOI: 10.1007/s00167-022-07195-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The aim of this study was to evaluate the clinical and imaging findings up to 24 months of follow-up in patients treated with combined subchondral and intra-articular bone marrow aspirate concentrate (BMAC) injections for the treatment of knee osteoarthritis (OA). METHODS Thirty consecutive patients (19 males, 11 females) aged between 40 and 75 years (mean age 56.4 ± 8.1 years) with unilateral symptomatic knee OA (Kellgren-Lawrence 2-3) were included in the study. Patients were treated with combined intra-articular and subchondral bone BMAC injections (total 9 ml) under fluoroscopic control. IKDC subjective score, VAS for pain, KOOS, and EQ-VAS were prospectively evaluated up to 24 months. Radiographs were performed at baseline and at 24 months after the procedure. MRI was evaluated with the WORMS score at baseline, 6-12 months, and 24 months of follow-up. The statistical analysis was performed using SPSS v.19.0 and for all tests p < 0.05 was considered significant. RESULTS No major complications and a 13% failure rate were reported. The IKDC subjective score remained stable from 62.6 ± 19.4 at 12 months to 63.4 ± 17.1 at 24 months (both p < 0.0005 compared to baseline, 40.5 ± 12.5). Similar improvements were reported for all KOOS subscales, while EQ-VAS did not report any significant improvement. VAS pain worsened from 3.0 ± 1.9 at 12 months to 4.4 ± 1.8 at the final follow-up (p = 0.0001), although remaining lower compared to the baseline value of 6.3 ± 1.8 (p = 0.002). The radiographic evaluation did not reveal signs of improvement or deterioration of the OA grade. The MRI findings showed a worsening in marginal osteophytes and synovitis, but a significant reduction of bone marrow edema at 24 months (p < 0.0005). CONCLUSION Combined intra-articular and subchondral BMAC injections provided clinical and imaging benefits up to 24 months for the treatment of symptomatic knee OA, with durable clinical results, a low failure rate, and a significant reduction of bone marrow edema.
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Affiliation(s)
- Elizaveta Kon
- IRCCS Humanitas Research Center, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Berardo Di Matteo
- IRCCS Humanitas Research Center, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | | | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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7
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Efficacy of a Novel Intra-Articular Administration of Platelet-Rich Plasma One-Week Prior to Hyaluronic Acid versus Platelet-Rich Plasma Alone in Knee Osteoarthritis: A Prospective, Randomized, Double-Blind, Controlled Trial. J Clin Med 2022; 11:jcm11113241. [PMID: 35683635 PMCID: PMC9181501 DOI: 10.3390/jcm11113241] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 12/19/2022] Open
Abstract
Recent studies have suggested that the combined injection of platelet-rich plasma (PRP) and hyaluronic acid (HA) may have additive benefits for knee osteoarthritis over PRP alone, but there is insufficient evidence to support this combined injection. Moreover, the simultaneous injection of PRP and HA may offset the combined effect. Hence, the aim of this prospective, randomized, double-blind study was to assess their combined efficacy with a novel injection protocol. Forty-six study subjects with unilateral knee osteoarthritis were randomized to receive either a single-dose injection of HA (intervention group) or normal saline (control group) 1 week after a single-dose injection of leukocyte-poor PRP. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and static balance and the risk of falls measured by Biodex Balance System were, respectively, the primary and secondary outcome measures. Evaluations were performed at baseline, 1 month, 3 months, 6 months, and 12 months post-injection. The intervention group exhibited significant declines in WOMAC pain, stiffness, and total scores, as well as static balance, compared to the control group (p < 0.05). These randomized double-blind control trials, with novel protocol of intra-articular injection of PRP 1-week prior to HA, provide greater symptom relief and improve static balance compared to PRP alone in patients with knee osteoarthritis.
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8
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Apinyankul R, Siriwattanasit K, Srungboonmee K, Witayakom W, Kosuwon W. A vibration sensor approach to detect intra-articular needle tip placement in the knee joint: a proof-of-concept study. BMC Musculoskelet Disord 2021; 22:946. [PMID: 34781957 PMCID: PMC8591594 DOI: 10.1186/s12891-021-04836-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 11/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-articular injection in the dry knee joint is technically challenging particularly for the beginners. The aim of this study was to investigate the possible use of the vibration sensor to detect if the needle tip was at the knee intra-articular position by characterizing the frequency component of the vibration signal during empty syringe air injection. METHODS Two milliliters of air were injected supero-laterally at extra- and intra-articular positions of a cadaveric knee joint, using needles of size 18, 21 and 24 gauge (G). Ultrasonography was used to confirm the positions of needle tip. A piezoelectric accelerometer was mounted medially on the knee joint to collect the vibration signals which were analyzed to characterize the frequency components of the signals during injections. RESULTS The vibration frequency band power in the range of 500-1500 Hz was visually observed to potentially localize the needle tip placement during air injection whether they were at the knee extra-articular or intra-articular positions, as demonstrated by the higher band power (over - 40 dB or dB) for all the needle sizes. The differences of frequency band power between extra- and intra-articular positions were 18.1 dB, 26.4 dB and 39.2 dB for the needle size 18G, 21G and 24G respectively. The largest difference in spectral power was found in the smallest needle diameter (24G). CONCLUSIONS A vibration sensor approach was preliminarily proved to distinguish the intra-articular from extra-articular needle placement in the knee joint. This study demonstrated a possible implementation of an alternative electronic device based on this technique to detect the intra-articular knee injection.
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Affiliation(s)
- Rit Apinyankul
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Kritsada Siriwattanasit
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Kakanand Srungboonmee
- Center of Data Mining and Biomedical Informatics, Faculty of Medical Technology, Mahidol University, Nakhonpathom, 73170, Thailand.
| | - Witchaporn Witayakom
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Weerachai Kosuwon
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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9
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Uson J, Rodriguez-García SC, Castellanos-Moreira R, O'Neill TW, Doherty M, Boesen M, Pandit H, Möller Parera I, Vardanyan V, Terslev L, Kampen WU, D'Agostino MA, Berenbaum F, Nikiphorou E, Pitsillidou IA, de la Torre-Aboki J, Carmona L, Naredo E. EULAR recommendations for intra-articular therapies. Ann Rheum Dis 2021; 80:1299-1305. [PMID: 34035002 PMCID: PMC8458067 DOI: 10.1136/annrheumdis-2021-220266] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/08/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies. METHODS A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence. RESULTS Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare. CONCLUSION We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.
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Affiliation(s)
- Jacqueline Uson
- Rheumatology Deptarment, Hospital Universitario Móstoles, Universidad Rey Juan Carlos, Madrid, Spain
| | | | - Raul Castellanos-Moreira
- Rheumatology Department, Centre Sociosanitari Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | - Terence W O'Neill
- Arthritis Research UK Centre for Epidemiology, The University of Manchester, Manchester, UK
| | - Michael Doherty
- Acaedemic Rheumatology, University of Nottingham, Nottingham, UK
| | - Mikael Boesen
- Musculoskeletal research Unit, Department of Radiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Hemant Pandit
- Orthopaedic Surgery, Chapel Allerton Hospital, University of Leeds, Leeds, UK
| | | | - Valentina Vardanyan
- Rheumatology Department, Yerevan State Medical University Named after Mkhitar Heratsi, Yerevan, Armenia
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Willm Uwe Kampen
- Nuclear Medicine Spitalerhof, Radiologische Allianz, Hamburg, Germany
| | - Maria-Antonietta D'Agostino
- Rheumatology Department, Università Cattolica del Sacro Cuore, Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | | | - Elena Nikiphorou
- Rheumatology Research, Acaedemic Department of Rheumatology, King's College London, London, UK
| | - Irene A Pitsillidou
- EULAR Patient Research Partner, Cyprus League Against Rheumatism, Nicosia, Cyprus
| | | | - Loreto Carmona
- Instituto de Salud Musculoesquelética (INMUSC), Madrid, Spain
| | - Esperanza Naredo
- Rheumatology Department and Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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10
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Jang KM, Park YG, Choi WK, Chung YY, Kim KK, Lee JW, Lee SJ, Eom Y, Yang JH. Safety of a single intra-articular injection of LBSA0103 hyaluronic acid in patients with osteoarthritis of the knee: a multicenter, single-arm, prospective, cohort study. Curr Med Res Opin 2021; 37:1573-1580. [PMID: 34192989 DOI: 10.1080/03007995.2021.1950132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE LBSA0103 is a recently developed high-molecular-weight, cross-linked, non-animal hyaluronic acid (HA). The safety of LBSA0103 has been investigated only in a limited number of patients, therefore this prospective study was designed. This study sought to assess the safety including injection-site reactions and adverse drug reactions after a single intra-articular injection of LBSA0103 in patients with osteoarthritis (OA) of the knee joint. METHODS This study was a multicenter, single-arm, prospective cohort study. After screening, eligible patients with OA of the knee joint (Kellgren-Lawrence grades I-III) were enrolled, received a single intra-articular HA (LBSA0103) injection, and were followed up for two weeks. Any adverse events including injection-site reactions and adverse drug reactions were evaluated by the investigators. RESULTS A total of 1949 subjects (2976 knee joints) was enrolled, all of whom received a single intra-articular injection of LBSA0103. Injection-site reactions occurred in 5.59% of enrolled subjects (109/1949), and the most frequently reported injection-site reaction was pain (4.87%), followed by swelling (1.03%). Most of the injection-site reactions were transient and resolved within 14 days without additional treatment. The incidence of adverse drug reactions other than injection-site reactions was 0.67% (13/1949). Most adverse events were of mild severity. No serious adverse events related to the study drug were reported. CONCLUSIONS A single intra-articular injection of LBSA0103 in patients with OA of the knee joint was safe, and no significant safety concerns were observed. As such, LBSA0103 could be safely applied as an intra-articular injection for the management of knee OA. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (identifier: NCT04369261).
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Affiliation(s)
- Ki-Mo Jang
- Department of Orthopedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yong-Geun Park
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Won Kee Choi
- Department of Orthopedic Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea
| | - Young Yool Chung
- Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Republic of Korea
| | - Kwang Kyoun Kim
- Department of Orthopedic Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Jang Woo Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Soong Joon Lee
- Department of Orthopedic Surgery, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Yunae Eom
- Life Sciences R&D, LG Chem, Ltd, Seoul, Republic of Korea
| | - Jae-Hyuk Yang
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, Republic of Korea
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11
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Ultrasound-Guided Knee Injections Are More Accurate Than Blind Injections: A Systematic Review of Randomized Controlled Trials. Arthrosc Sports Med Rehabil 2021; 3:e1177-e1187. [PMID: 34430899 PMCID: PMC8365196 DOI: 10.1016/j.asmr.2021.01.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/30/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To review the current literature to determine which injection technique and needle portal placement provide the greatest accuracy for intra-articular access to the knee. Methods This study followed Preferred Reporting Items and Systematic Reviews and Meta-Analyses guidelines. A comprehensive literature search was conducted in March 2020 and repeated in May 2020 using electronic databases PubMed, MEDLINE, and the Cochrane Library. Data on the accuracy of intra-articular knee injection (successful injections/total number of injections) were collected. Only Level I studies were included. Study design, demographic variables, needle sizes, and method of validating accuracy were recorded. The Jadad score was used to assess methodologic quality, and a risk-of-bias assessment was performed. Results A total of 12 Level I human studies (1431 patients, 1315 knees) were included in this review. Seven of the studies did a direct comparison between ultrasound-guided and blind knee injections. Ultrasound-guided injections were more accurate compared with blinded knee injections in every study. The most accurate anatomical approach was an isometric quadricep contraction method with the superolateral approach. Conclusions This study showed that ultrasound-guided knee injections were more accurate across every anatomical needle injection site compared with blind injections. Injections made by a blind/anatomically guided method had inconsistent accuracy rates that seemed highly dependent on the portal of entry. Level of Evidence Level I, systematic review of Level I studies.
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12
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Gavín C, J Blanco F, L Pablos J, Caracuel MA, Rosas J, Gómez-Barrena E, Navarro F, Coronel MP, Gimeno M. One-Year, Efficacy and Safety Open Label Study, with a Single Injection of a New Hyaluronan for Knee OA: The SOYA Trial. J Pain Res 2021; 14:2229-2237. [PMID: 34321921 PMCID: PMC8312328 DOI: 10.2147/jpr.s321841] [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: 05/25/2021] [Accepted: 07/06/2021] [Indexed: 01/07/2023] Open
Abstract
Purpose To assess the efficacy and safety of a single injection of a new formulation of hyaluronic acid (MPS-HA2%) in patients with symptomatic knee osteoarthritis after 12 months’ follow-up. Patients and Methods Prospective, single-arm, multicentre, open-label, 12-month follow-up study. Patients with Kellgren–Lawrence (KL) 2–3 and visual analogue scale (VAS) pain scores of ≥40–< 80 mm received a single injection of MPS-HA2%. The primary outcome was the reduction in VAS pain scores from baseline, and the secondary outcomes were the Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Index, the minimum clinically important improvement (MCII), and patient and investigator global assessments (PGA, IGA) measured on 5-point Likert scale. Adverse events were recorded throughout the study for safety purposes. Results A total of 101 patients (mean age: 68 years; 74% female; and 78% overweight) were included. The mean reduction in pain at 12 months was 37.7%; the total WOMAC score improved by 36.5% and the pain, stiffness and physical function subscores returned improvements of 32.1%, 34.1% and 32.7%, respectively (p=0.0001 with respect to baseline). At 12 months, a statistically significant 62.2% of patients obtained an improvement equal to or greater than the MCII. The mean PGA score at baseline was 2.44 and 1.46 at 12 months (p<0.05), and the mean IGA scores at equivalent timepoints were 2.29 and 1.48 (p<0.05). Fourteen patients received a second injection at the 6-month follow-up visit. Eight patients reported a total of 12 treatment-related adverse events that were local, non-serious and of mild-to-moderate intensity. Conclusion With just a single intra-articular injection, this not controlled trial suggests that MPS-HA2% is effective 12 months after the procedure in most cases. Patient tolerability and safety were both optimal (NCT03852914).
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Affiliation(s)
- Carlos Gavín
- Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | | | | | - José Rosas
- Hospital Marina Baixa, Villajoyosa, Alicante, Spain
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13
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Hayashi D, Roemer FW, Guermazi A. How to effectively utilize imaging in disease-modifying treatments for osteoarthritis clinical trials: the radiologist's perspective. Expert Rev Mol Diagn 2021; 21:673-684. [PMID: 34015975 DOI: 10.1080/14737159.2021.1933444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction: One of the reasons for failures of disease-modifying osteoarthritis drug clinical trials has been the radiography-based definition of structural eligibility criteria. Imaging, particularly MRI, has a critical role in planning and conducting clinical trials of osteoarthritis.Areas covered: A literature search was performed using keywords including 'osteoarthritis,' 'knee,' 'MRI,' 'intra-articular injection,' 'semiquantitative scoring,' 'clinical trial,' and other specific terms where relevant. The core concepts of using MRI in osteoarthritis clinical trials are explained focusing on knee osteoarthritis, including its role in determining patient eligibility and inclusion/exclusion criteria as well as outcome measures from the expert musculoskeletal radiologist's perspective. A brief overview of statistical analyses that should be deployed in clinical trials utilizing semiquantitative MRI analyses is discussed.Expert opinion: In order to increase chances to detect measurable efficacy effects, investigators should consider utilizing MRI from screening to outcome assessment. Recognition of several phenotypes of osteoarthritis helps in participant stratification and will lead to more targeted clinical trials. Inclusion and exclusion criteria need to be defined using not only radiography but also MRI. Correct intra-articular injection of investigational compounds is critically important if intra-articular drug delivery is required, and such procedure should be performed and documented using appropriate imaging guidance.
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Affiliation(s)
- Daichi Hayashi
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, Boston, MA, USA.,Department of Radiology, Stony Brook University, Renaissance School of Medicine, State University of New York, Stony Brook, NY, USA
| | - Frank W Roemer
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, Boston, MA, USA.,Department of Radiology, Friedrich-Alexander University Erlangen-Nuremberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Ali Guermazi
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, Boston, MA, USA.,Department of Radiology, Veterans Affairs Boston Healthcare System, Boston, MA, USA
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14
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Difference in pain and accuracy of two hyaluronic acid injection techniques for symptomatic knee osteoarthritis in overweight patients. Reumatologia 2021; 59:23-26. [PMID: 33707792 PMCID: PMC7944963 DOI: 10.5114/reum.2021.103646] [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: 04/27/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives To evaluate differences of injection related pain, and the accuracy of the techniques in two groups of overweight patients, performing the anterolateral approach for one group (G1) and the superolateral approach for the second group (G2). Material and methods In the study, 126 knee joints from 86 osteoarthritis (OA) patients were evaluated. Inclusion criteria were body mass index (BMI) ≥ 25, absence of effusion and coagulopathy. Pain evaluation during injection was evaluated with Visual Analogue Scale (VAS), while accuracy of the procedure was evaluated with ultrasound (US). Results The patients’ mean age was 69.9 ±9.01, VAS for G1 group was 1.71 ±1.89, for G2 group was 1.74 ±1.31. Mean BMI was 29.69 ±2.86, for G1 group was 28.29 ±3.29, for G2 group was 30.32 ±2.41. No adverse events (AE) occurred in both studied groups. The accuracy rate of the procedure was 69.1% for G1 (38/55 knees), 95.7% for G2 (68/71 knees). No significant difference was found in VAS pain score between G1 and G2 group (p = 0.45). We found the significant correlation between BMI and VAS pain score in anterolateral accesses (G1) (r = 0.51; p < 0.005). No correlation was found between age and VAS pain score in anterolateral access (G1). For the superolateral access (G2), no correlation was found for age or BMI and VAS pain score. Conclusions Hyaluronic acid injection is safe therapeutic option for knee OA with no significant differences between anterolateral and superolateral approaches in terms of pain in overweight patients. However, higher BMI seems to be a predictor of pain in anterolateral access, and the superolateral approach should be preferred in this group of patients.
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15
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Dulic O, Lalic I, Kecojevic V, Gavrilovic G, Abazovic D, Miskulin M, Maric D, Bumbasirevic M. Do knee injection portals affect clinical results of bone marrow aspirate concentrate injection in the treatment of osteoarthritis? A prospective randomized controlled study. Regen Med 2020; 15:1987-2000. [PMID: 33151802 DOI: 10.2217/rme-2020-0020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim: To explore the effect that the location of needle placement has on efficacy and tolerability of bone marrow aspirate concentrate injections during treatment of knee osteoarthritis. Methods: Bone marrow aspirate concentrate injections were administered to 111 patients via superolateral, anteromedial or anterolateral portals. Pain was assessed by visual analog scale before and 3, 7, 14 and 21 days after intervention. Knee function was assessed by Western Ontario and McMaster Universities Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores before and 1, 3, 6, 9 and 12 months after intervention. Results: Significant differences in Western Ontario and McMaster Universities Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores were observed 12 months post intervention compared with baseline (p < 0.001 for all comparisons). No significant differences in outcome or pain scores were observed among groups. Conclusion: All portals demonstrated similar clinical benefits up to 12 months after intervention. Trial registration number: ClinicalTrials.gov (NCT03825133).
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Affiliation(s)
- Oliver Dulic
- University of Novi Sad, Medical Faculty, Clinical Center of Vojvodina, Department for Orthopedic Surgery & Traumatology, Hajduk Veljkova 1-9, Novi Sad, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Ivica Lalic
- University of Novi Sad, Medical Faculty, Clinical Center of Vojvodina, Department for Orthopedic Surgery & Traumatology, Hajduk Veljkova 1-9, Novi Sad, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Vaso Kecojevic
- University of Novi Sad, Medical Faculty, Clinical Center of Vojvodina, Department for Orthopedic Surgery & Traumatology, Hajduk Veljkova 1-9, Novi Sad, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Gordan Gavrilovic
- Atlas Hospital, Osmana Djikica 5, Belgrade, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Dzihan Abazovic
- Renova Hospital, Osmana Djikica 5, Belgrade, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Mladen Miskulin
- Specijalna bolnica za Neurokirurgiju i ortopediju Aksis, Zagreb, Petrovaradinska 1, 10000 ZAGREB, Croatia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Dusan Maric
- MD Orto Hospital, Futoski put 115, Novi Sad, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
| | - Marko Bumbasirevic
- University of Belgrade, Medical Faculty, Clinical Center of Serbia, Clinic for Orthopedic Surgery & Traumatology, Dr. Subotica 20, Belgrade, Serbia.,Department for Orthopedic Surgery & Traumatology Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia
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Seki Y, Katagiri H, Otabe K, Nakagawa Y, Miyatake K, Sekiya I, Koga H. Investigation of association between the preoperative intra-articular anesthetic test and persistent pain after total knee arthroplasty. J Orthop Sci 2020; 25:1055-1060. [PMID: 32107135 DOI: 10.1016/j.jos.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 12/12/2019] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND A better understanding of the etiology of persistent pain after total knee arthroplasty (TKA) is required to prevent unfavorable outcomes. The purpose of this study was to investigate the association of persistent pain after TKA, patient characteristics, and the remaining pain ratio per the preoperative intra-articular anesthetic test. METHODS This study included 89 patients who underwent TKA and underwent an intra-articular anesthetic test preoperatively. The remaining pain ratio out of 100 percent 30 min after intra-articular anesthetic injection and demographic data were also evaluated preoperatively. Numerical rating scale (NRS) scores for pain during movement (Q1), at rest (Q2), at first movement in the morning (Q3), and during climbing up and down stairs (Q4) were evaluated 1 year after TKA. Multiple linear regression analysis was performed to assess the impact of independent variables on the NRS score for questionnaire No.4. and the remaining pain ratio per the intra-articular anesthetic. RESULTS The mean remaining pain ratio per the preoperative intra-articular anesthetic test was 29.3%. The NRS score for Q4 was significantly higher than those for any of the other NRS questionnaires administered 1 year after TKA (Q1-Q4, Q2-Q4, P < 0.001; Q3-Q4, P < 0.05). The analysis found the weak correlation between the pain ratio of anesthetic test and the NRS score for Q4 after TKA (R = 0.28, P = 0.018). BMI and preoperative FTA were the major predictors of remaining pain ratio per the intra-articular anesthetic test (R = 0.40, P = 0.002). CONCLUSION This study revealed that the remaining pain ratio per the preoperative intra-articular anesthetic test was weakly correlated with persistent pain during climbing up and down stairs 1 year after TKA. In addition, BMI and preoperative FTA were associated with the remaining pain ratio per the preoperative intra-articular anesthetic test.
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Affiliation(s)
- Yoshie Seki
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koji Otabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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17
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Current Variation in Joint Aspiration Practice for the Evaluation of Pediatric Septic Arthritis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00133. [PMID: 32890012 PMCID: PMC7469993 DOI: 10.5435/jaaosglobal-d-20-00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric septic arthritis (SA) is a condition that can be associated with significant morbidity. Although previous research has been on predictive care pathways, scrutiny of the literature continues to reveal wide differences in the patient evaluation and management. The purpose of this study was to define the differences in joint aspiration for the evaluation of pediatric SA across pediatric tertiary care institutions in the United States.
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18
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Mol MF, Runhaar J, Bos PK, Dorleijn DMJ, Vis M, Gussekloo J, Bindels PJE, Bierma-Zeinstra SMA. Effectiveness of intramuscular gluteal glucocorticoid injection versus intra-articular glucocorticoid injection in knee osteoarthritis: design of a multicenter randomized, 24 weeks comparative parallel-group trial. BMC Musculoskelet Disord 2020; 21:225. [PMID: 32278346 PMCID: PMC7149870 DOI: 10.1186/s12891-020-03255-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/31/2020] [Indexed: 12/17/2022] Open
Abstract
Background The knee is symptomatically the most frequent affected joint in osteoarthritis and, in the Netherlands and other Western countries, is mainly managed by general practitioners (GPs). An intra-articular glucocorticoid injection is recommended in (inter) national guidelines for patients with knee osteoarthritis as an option for a flare of knee pain and/or for those who are not responding well to pain medication. An innovative approach that could replace the intra-articular injection is an intramuscular gluteal glucocorticoid injection. An intramuscular injection is easier to perform than an intra-articular injection with lesser risk of severe local adverse reactions. We hypothesize that intramuscular gluteal glucocorticoid injection is non-inferior in reducing knee pain compared to intra-articular glucocorticoid injection, with potentially a longer lasting effect than intra-articular injection. Methods/design The study will be a pragmatic randomized controlled non-inferiority trial with two parallel groups. A total of 140 patients aged 45 years and older with knee osteoarthritis who contacted their general practitioner and have persistent knee pain (score ≥ 3 on 0–10 numerical rating scale; 0 = no knee pain) will be included. Patients will be randomly allocated (1:1) to an injection of 40 mg triamcinolone acetonide intra-articular in the knee joint or intramuscular in the ipsilateral ventrogluteal area. The effect of treatment will be evaluated by questionnaires at 2, 4, 8, 12, and 24 weeks after injection. The primary outcome is patients’ reported severity of knee pain measured with the pain subscale of the Knee injury and Osteoarthritis Outcome Score 4 weeks after injection. Statistical analysis will be based on both the per-protocol and the intention-to-treat principle. Discussion This study will evaluate non-inferiority of intramuscular glucocorticoid injection compared to intra-articular glucocorticoid injection for knee osteoarthritis symptoms. Trial registration This trial is registered in the Dutch Trial Registry (number NTR6968) at 2018-01-22 (https://www.trialregister.nl/trial/6784). Issue date: 1 October 2019. Trial sponsor Erasmus MC University Medical Center Rotterdam. PO-box 2040. 3000 CA Rotterdam. The Netherlands.
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Affiliation(s)
- Marianne F Mol
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, PO-box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Jos Runhaar
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, PO-box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - P Koen Bos
- Department of Orthopaedic Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Desirée M J Dorleijn
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marijn Vis
- Department of Rheumatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Section of Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, PO-box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, PO-box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of Orthopaedic Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Conrozier T, Monfort J, Chevalier X, Raman R, Richette P, Diraçoglù D, Bard H, Baron D, Jerosch J, Migliore A, Henrotin Y. EUROVISCO Recommendations for Optimizing the Clinical Results of Viscosupplementation in Osteoarthritis. Cartilage 2020; 11:47-59. [PMID: 29926748 PMCID: PMC6921960 DOI: 10.1177/1947603518783455] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The 3 aims of the work were to identify population subgroups that can benefit the most from viscosupplementation (VS), to provide recommendations on injection techniques, and to discuss VS appropriateness in clinical situations that are commonplace in daily practice. METHODS The task force members voted on their degree of agreement on 27 statements, 36 recommendations, and 22 clinical scenarios using a 9-point scale. The strength of agreement/appropriateness/recommendation (SOA/SOR) was classified as strong if the median agreement score was ≥8. The level of consensus (LOC) was also obtained. RESULTS Among the assumed predictors for VS failure, obesity, radiographic severity, large synovial fluid effusion, severe patellofemoral involvement, major malalignment, and gross joint instability received a large majority of agreements. The lateral mid-patellar approach was recommended for knee injection. Imaging guidance was unanimously recommended for hip and ankle. Agreement was achieved to strictly respect the dosing regimen proven by controlled trials. There was agreement for treating with VS patients with mild to moderate knee and hip OA, with normal weight or moderate overweight, insufficiently improved by first-line therapies, or who do not wish get oral treatment or who have contraindications to pain killers. The group considered the patient's wishes as a key element in therapeutic decision making. CONCLUSION Based on literature data and clinical experience, the EUROVISCO group proposed a set of recommendations for optimizing the results of VS, aimed to help practitioners, especially in some cases in which the patients' specificities make the therapeutic decision difficult.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord
Franche-Comté, Belfort, France,Thierry Conrozier, Department of
Rheumatology, Hôpital Nord Franche-Comté, 100 route de MOVAL, CS 10499
Trevenans, 90015 Belfort, France.
| | - Jordi Monfort
- Servei de Reumatologia, Hospital del
Mar, Barcelona, Spain
| | - Xavier Chevalier
- Paris XII University, UPEC, Department
of Rheumatology, Henri Mondor Hospital, Creteil, France
| | - Raghu Raman
- Academic Department of Orthopaedics,
Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
| | - Pascal Richette
- Université Paris Diderot, UFR Médicale,
Hôpital Lariboisière, Paris, France
| | - Demirhan Diraçoglù
- Department of Physical Medicine and
Rehabilitation, Istanbul University and Istanbul Faculty of Medicine, Istanbul,
Turkey
| | - Hervé Bard
- Department of Orthopaedics-Rheumatology,
American Hospital of Paris, Neuilly/Seine, France
| | - Dominique Baron
- Centre de réadaptation fonctionnelle de
Lannion-Trestel, Trévou-Tréguignec, France
| | - Jörg Jerosch
- Orthopedic Department,
Johanna-Etienne-Hospital, Neuss, Nordrhein-Westfalen, Germany
| | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San
Pietro Fatebenefratelli, Rome, Italy
| | - Yves Henrotin
- Bone and Cartilage Research Unit,
Université de Liège, CHU Sart-Tilman, Liège, Belgium
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20
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Hermans J, Bierma-Zeinstra SMA, Bos PK, Niesten DD, Verhaar JAN, Reijman M. The effectiveness of high molecular weight hyaluronic acid for knee osteoarthritis in patients in the working age: a randomised controlled trial. BMC Musculoskelet Disord 2019; 20:196. [PMID: 31064359 PMCID: PMC6503549 DOI: 10.1186/s12891-019-2546-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 03/28/2019] [Indexed: 01/27/2023] Open
Abstract
Background High molecular weight (HMW) hyaluronic acid (HA) is a treatment option for knee osteoarthritis (OA). The efficacy of HMW-HA in knee OA is investigated extensively, but the effectiveness in patients in the working age is unknown. Nevertheless, the number knee OA patients in the working age is increasing. Surgical treatment options are less eligible in these patients and productivity losses are high. In this study the effectiveness of intra-articular HMW-HA added to regular non-surgical usual care in everyday clinical practice (UC) compared to UC over 52 weeks in symptomatic knee OA patients in the working age was investigated. Methods In this open labelled randomized controlled trial, subjects aged between 18 and 65 years with symptomatic knee OA (Kellgren and Lawrence I-III) were enrolled and randomized to UC + 3 weekly injections with HMW-HA (intervention) or UC only (control). The primary outcome was the between group difference in responders to therapy according to OMERACT-OARSI criteria after 52 weeks. These criteria include the domains pain, knee related function and patient’s global assessment (PGA). Function was evaluated with the KOOS questionnaire. Pain was assessed with the Numeric Rating Scale. Secondary outcome comprised the between group difference on the individual responder domains, as analysed with a random effects model. Odds Ratios (OR) were calculated by logistic regression analysis. Sensitivity analyses were performed. Results In total, 156 subjects were included (intervention group 77, control group 79). Subjects in the intervention group (HMW-HA + UC) were more often responder compared to the controls (UC). Depending on whether pain during rest or pain during activity was included in the responder domains, 57.1% versus 34.2% (p = 0.006) and 54.5% versus 34.2% (p = 0.015) was responder to therapy respectively. The results of the secondary outcome analyses show that scores on individual responder domains over all follow-up moments were statistically significant in favour of the intervention group in the domains pain during rest (δ 0.8, 95%CI 0.2; 1.4, p = 0.010), knee related function (δ − 6.8, 95%CI -11.9; − 1.7, p = 0.010) and PGA (δ − 0.7, 95%CI -0.9; − 0.4, p < 0.0001). Conclusions Intra-articular HMW-HA added to usual care is effective for knee OA in patients in the working age. Trial registration www.trialregister.nl, NTR1651, registered 2009-3-3. Electronic supplementary material The online version of this article (10.1186/s12891-019-2546-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Job Hermans
- Department of Orthopaedic Surgery, Erasmus University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Sita M A Bierma-Zeinstra
- Department of Orthopaedic Surgery, Erasmus University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of General Practice, Erasmus University Medical Centre, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Pieter K Bos
- Department of Orthopaedic Surgery, Erasmus University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Dieu Donne Niesten
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, PO Box 5011 2600, GA, Delft, The Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedic Surgery, Erasmus University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Max Reijman
- Department of Orthopaedic Surgery, Erasmus University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
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Chernchujit B, Tharakulphan S, Apivatgaroon A, Prasetia R. Accuracy comparisons of intra-articular knee injection between the new modified anterolateral Approach and superolateral approach in patients with symptomatic knee osteoarthritis without effusion. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2019; 17:1-4. [PMID: 30976521 PMCID: PMC6438910 DOI: 10.1016/j.asmart.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/21/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
Background Intra-articular knee injection with steroid or various other agents have been used to control the local inflammation and relieve pain in the osteoarthritis knee. To achieve the maximal potential therapeutic worth and decrease the complications from the inaccurate knee injection, these medications should be delivered directly into the intra-articular space. Injection technique is one of the most important factors for accuracy of knee injection. Therefore, this study was aimed to propose the new modified anterolateral injection technique for higher accuracy of knee injection in symptomatic osteoarthritis knee without effusion. Material and methods Patients with symptomatic osteoarthritis without effusion were included prospectively from May 2014 to May 2015 and randomized into 2 groups for knee injection: Modified anterolateral (MAL), Standard superolateral (SL). Knee injection was performed by one experienced orthopaedic. Accuracy of injection was test by mini air-arthrography technique. The pain from injection were evaluated by visual analog scale (VAS). Result 132 knees were included, 66 knees were modified anterolateral group same as superolateral group. The modified anterolateral injection was significantly yield the higher accuracy rate than the standard superolateral injection (89% vs 58%, P < 0.05). The pain visual analog scale was not significantly different between the modified anterolateral and standard superolateral injection technique (2.61 vs 2.65, P = 0.917) No adverse events were occurred. Conclusion The new modified anterolateral injection yields the higher pooled accuracy rate. From the accuracy and the advantage of the new modified anterolateral injection, this is the preferred injection technique for the symptomatic osteoarthritis without knee effusion.
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Affiliation(s)
- Bancha Chernchujit
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | - Adinun Apivatgaroon
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Renaldi Prasetia
- Department of Orthopedics and Traumatology Universitas Padjadjaran, Dr. Hasan Sadikin Teaching Hospital, Bandung, Indonesia
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22
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Wada M, Fujii T, Inagaki Y, Nagano T, Tanaka Y. Isometric Contraction of the Quadriceps Improves the Accuracy of Intra-Articular Injections into the Knee Joint via the Superolateral Approach. JB JS Open Access 2018; 3:e0003. [PMID: 30882048 PMCID: PMC6400508 DOI: 10.2106/jbjs.oa.18.00003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Intra-articular injection is an important technique for treating rheumatoid arthritis and osteoarthritis of the knee. However, medication is often inaccurately injected outside of the joint. We devised an intra-articular injection method in which the needle is inserted into the suprapatellar bursa while the patient maintains isometric contraction of the quadriceps. This isometric contraction method is based on the concept that isometric contraction of the quadriceps induces contraction of the articularis genus muscle, thus expanding the lumen of the suprapatellar bursa. Methods: Intra-articular injections were performed on 150 osteoarthritic knees without effusion. The knees were alternately assigned to the isometric quadriceps method group (75 knees) and non-activated quadriceps method group (75 knees). Prior to joint injection, the anterior-posterior dimension of each suprapatellar bursa was measured to ascertain its expansion. The isometric quadriceps method was performed with the quadriceps and the articularis genus muscle maintained in a contracted state. The non-activated quadriceps method was performed in a relaxed state. Ultrasound guidance was not used for either method. Subsequently, an ultrasonic probe was used only to confirm whether the intra-articular injections were successful. We compared the accuracy of injections performed between the 2 groups. Results: Suprapatellar expansion was significantly larger (p < 0.001) using the isometric quadriceps method (2.1 ± 1.4 mm [range, 0 to 5 mm]) than using the non-activated quadriceps method (0.8 ± 0.7 mm [range, 0 to 2 mm]). The percentage of accurate intra-articular injections was significantly higher (p = 0.0287) using the isometric quadriceps method (93%) compared with the non-activated quadriceps method (80%). Conclusions: In comparison with the non-activated quadriceps method, the isometric quadriceps method led to a larger expansion of the suprapatellar bursa, which should lead to more accurate intra-articular injections. The isometric quadriceps method is effective in reducing inaccurate injections into the synovium or surrounding fatty tissues. Clinical Relevance: Putting force on the quadriceps muscle increases the success rate of intra-articular injection of the knee. The results of this study could provide a clinically relevant injection technique for future treatment.
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Affiliation(s)
- Makoto Wada
- Department of Orthopaedic Surgery, Wada Orthopaedic Clinic, Hirakata, Japan
| | - Tadashi Fujii
- Department of Orthopaedic Surgery, Kashiba Asahigaoka Hospital, Kashiba, Japan
| | - Yusuke Inagaki
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Japan
| | - Tatsuo Nagano
- Department of Orthopaedic Surgery, Nagano Orthopaedic Clinic, Kashiba, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Japan
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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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Simoni P, Malaise O, El Hachemi M, Tromba A, Boitsios G. Learning curves of two different techniques for the intra-articular injection of the knee joint under fluoroscopic guidance. Radiol Med 2018; 123:359-366. [PMID: 29292479 DOI: 10.1007/s11547-017-0847-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 12/17/2017] [Indexed: 12/29/2022]
Abstract
AIM The aim of the study was to compare the learning curves of three beginner operators using two different techniques of intra-articular injection of the knee under fluoroscopic guidance with a superolateral approach. MATERIALS AND METHODS In total, 177 consecutive patients (72 females (40.7%) and 105 males (59.3%), mean age 42.2 ± 15.0 years) scheduled for a computed tomography (CT) arthrography and without joint effusion on the lateral X-rays were enrolled. They underwent an intra-articular injection of the knee under fluoroscopic guidance with a superolateral approach. Patients were randomly assigned to three different operators, including a junior supervisor and two first-year residents in radiology who never performed an intra-articular injection of the knee before the present study. Procedures in lateral or supine position were randomly assigned to three operators. RESULTS There was a higher rate of successful injections with the lateral position (92.1%) than with supine position (80.2%) (odds ratio (OR) 4.52, 95% confidence interval (CI) 1.46-14.0). A significant learning effect was observed for the supine position, while none was observed for the lateral position. Pain and time of fluoroscopy did not differ between the two procedures (p = 0.85 and p = 0.10, respectively). Junior supervisor had a higher rate of successful intra-articular injection compared with the other two operators (p = 0.0072). There was a statistically significant higher rate of extravasation with the supine position (66.3%) than with lateral position (19.7%) (p < 0.0001, OR 0.13, 95% CI 0.06-0.25). CONCLUSION The intra-articular injection of the knee under fluoroscopic guidance with the patient in lateral position is an easy technique for operators in training with a low rate of extravasation. Lateral position does not require a supplementary irradiation and does not increase the procedural pain. Personal operator's skill is an independent factor in determining the success of the training.
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Affiliation(s)
- Paolo Simoni
- "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles (ULB), 15, Avenue Jean Joseph Crocq, 1020, Brussels, Belgium. .,Rheumatology Department, CHU de Liège, CHU du Sart Tilman, Bât. 35, 4000, Liège, Belgium.
| | - Olivier Malaise
- Rheumatology Department, CHU de Liège, CHU du Sart Tilman, Bât. 35, 4000, Liège, Belgium
| | - Mounia El Hachemi
- Radiology Department, CHU de Liège, CHU du Sart Tilman, Bât. 35, 4000, Liège, Belgium
| | - Angelo Tromba
- Radiology Department, CHU de Liège, CHU du Sart Tilman, Bât. 35, 4000, Liège, Belgium
| | - Grammatina Boitsios
- "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles (ULB), 15, Avenue Jean Joseph Crocq, 1020, Brussels, Belgium
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Hermans J, Reijman M, Goossens LMA, Verburg H, Bierma-Zeinstra SMA, Koopmanschap MA. Cost-Utility Analysis of High Molecular Weight Hyaluronic Acid for Knee Osteoarthritis in Everyday Clinical Care in Patients at a Working Age: An Economic Evaluation of a Randomized Clinical Trial. Arthritis Care Res (Hoboken) 2017; 70:89-97. [DOI: 10.1002/acr.23242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/14/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Job Hermans
- Erasmus MC University Medical Centre; Rotterdam The Netherlands
| | - Max Reijman
- Erasmus MC University Medical Centre; Rotterdam The Netherlands
| | - Lucas M. A. Goossens
- Institute of Health Policy and Management; Erasmus University; Rotterdam The Netherlands
| | | | | | - Marc A. Koopmanschap
- Institute of Health Policy and Management; Erasmus University; Rotterdam The Netherlands
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McCormack R, Lamontagne M, Vannabouathong C, Deakon RT, Belzile EL. Comparison of the 3 Different Injection Techniques Used in a Randomized Controlled Study Evaluating a Cross-Linked Sodium Hyaluronate Combined With Triamcinolone Hexacetonide (Cingal) for Osteoarthritis of the Knee: A Subgroup Analysis. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2017; 10:1179544117725026. [PMID: 28839449 PMCID: PMC5560514 DOI: 10.1177/1179544117725026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/05/2017] [Indexed: 12/31/2022]
Abstract
A recent trial demonstrated that patients with knee osteoarthritis treated with a sodium hyaluronate and corticosteroid combination (Cingal) experienced greater pain reductions compared with those treated with sodium hyaluronate alone (Monovisc) or saline up to 3 weeks postinjection. In this study, injections were administered by 1 of 3 approaches; however, there is currently no consensus on which, if any, of these techniques produce a more favorable outcome. To provide additional insight on this topic, the results of the previous trial were reanalyzed to determine whether (1) the effect of Cingal was significant within each injection technique and (2) pain reductions were similar between injection techniques across all treatment groups. Greater pain reductions with Cingal up to 3 weeks were only significant in the anteromedial subgroup. Across all therapies, both the anteromedial and anterolateral techniques demonstrated significantly greater pain reductions than the lateral midpatellar approach at 18 and 26 weeks.
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Affiliation(s)
- Robert McCormack
- Department of Orthopaedics, The University of British Columbia, Vancouver, BC, Canada
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Yang J, Ward E, Sung TW, Wang J, Barback C, Mendez N, Blair S, Trogler WC, Kummel AC. Silica Shells/Adhesive Composite Film for Color Doppler Ultrasound Guided Needle Placement. ACS Biomater Sci Eng 2017; 3:1780-1787. [PMID: 33429658 DOI: 10.1021/acsbiomaterials.7b00223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ultrasound (US) guided medical devices placement is a widely used clinical technology, yet many factors affect the visualization of these devices in the human body. In this research, an ultrasound-activated film was developed that can be coated on the surface of medical devices. The film contains 2 μm silica microshells and poly(methyl 2-cyanoacrylate) (PMCA) adhesive. The air sealed in the hollow space of the microshells acted as the US contrast agent. Ozone and perfluorooctyltriethoxysilane (PFO) were used to treat the surface of the film to enhance the US signals and provide durable antifouling properties for multiple passes through tissue, consistent with the dual oleophobic and hydrophobic nature of PFO. In vitro and in vivo tests showed that hypodermic needles and tumor marking wires coated with US activated film gave strong and persistent color Doppler signals. This technology can significantly improve the visibility of medical devices and the accuracy of US guided medical device placement.
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Affiliation(s)
| | - Erin Ward
- Department of Surgery, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103, United States
| | | | | | - Christopher Barback
- Department of Radiology, University of California, San Diego, 410 Dickinson Street, San Diego, California 92103, United States
| | | | - Sarah Blair
- Department of Surgery, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103, United States
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28
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In-Plane Ultrasound-Guided Knee Injection Through a Lateral Suprapatellar Approach: A Safe Technique. Ultrasound Q 2017; 33:139-143. [PMID: 28481763 DOI: 10.1097/ruq.0000000000000288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aims to describe a technique for in-plane ultrasound-guided knee arthrography through a lateral suprapatellar approach, reporting its accuracy and related complications. METHODS A retrospective search was performed for computed tomography and magnetic resonance reports from June 2013 through June 2015. Imaging studies, puncture descriptions, and guided-procedure images were reviewed along with clinical and surgical history. A fellowship-trained musculoskeletal radiologist performed all procedures under sterile technique and ultrasound guidance with the probe in oblique position on the lateral suprapatellar recess after local anesthesia with the patient on dorsal decubitus, hip in neutral rotation, and 30 to 45 degrees of knee flexion. RESULTS A total of 86 consecutive subjects were evaluated (mean, 55 years). All subjects underwent intra-articular injection of contrast, which was successfully reached in the first attempt in 94.2% of the procedures (81/86), and in the second attempt in 5.8% (5/86) after needle repositioning without a second puncture. There were no postprocedural reports of regional complications at the puncture site, such as significant pain, bleeding, or vascular lesions. CONCLUSIONS Our study demonstrates that in-plane ultrasound-guided injection of the knee in semiflexion approaching the lateral suprapatellar recess is a safe and useful technique to administer intra-articular contrast solution, as an alternative method without radiation exposure.
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29
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Bellamy JL, Goff BJ, Sayeed SA. Economic Impact of Ketorolac vs Corticosteroid Intra-Articular Knee Injections for Osteoarthritis: A Randomized, Double-Blind, Prospective Study. J Arthroplasty 2016; 31:293-7. [PMID: 27402605 DOI: 10.1016/j.arth.2016.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Knee osteoarthritis is a disabling disease that costs billions of dollars to treat. Corticosteroid gives varying pain relief and costs $12 per injection, whereas ketorolac costs $2 per injection, per institutional costs. The aim of this study was to compare ketorolac with corticosteroid based on pain relief using patient outcome measures and cost data. METHODS A total of 35 patients were randomized to ketorolac or corticosteroid intra-articular knee injection in a double-blind, prospective study. Follow-up was 24 weeks. Osteoarthritis was evaluated using Kellgren-Lawrence grading. Visual analog scale (VAS) was the primary outcome measure. A query of the institutional database was performed for International Classification of Diseases, Ninth Revision codes 715.16 and 719.46, and procedure code 20610 over a 3-year period. Two-way, repeated measures analysis of variance and Spearman rank correlation were used for statistical analysis. RESULTS Mean VAS for ketorolac and corticosteroid decreased significantly from baseline at 2 weeks, 6.3-4.6 and 5.2-3.6, respectively and remained decreased for 24 weeks. There was no correlation between VAS and demographics within treatments. There were 220, 602, and 405 injections performed on patients with the International Classification of Diseases, Ninth Revision codes 715.16 and 719.46 during 2013, 2014, and 2015, respectively. The cost savings per year using ketorolac instead of corticosteroid would be $2259.40, $6182.54, and $4159.35 for 2013, 2014, and 2015, respectively, with a total savings of $12,601.29 over this period. CONCLUSION Pain relief was similar between ketorolac and corticosteroid injections. Ketorolac knee injection is safe and effective with a cost savings percentage difference of 143% when compared with corticosteroid.
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Affiliation(s)
- Jaime L Bellamy
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Brandon J Goff
- Department of Pain Management, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Siraj A Sayeed
- South Texas Bone and Joint Institute, San Antonio, Texas
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30
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van Tiel J, Siebelt M, Reijman M, Bos PK, Waarsing JH, Zuurmond AM, Nasserinejad K, van Osch GJVM, Verhaar JAN, Krestin GP, Weinans H, Oei EHG. Quantitative in vivo CT arthrography of the human osteoarthritic knee to estimate cartilage sulphated glycosaminoglycan content: correlation with ex-vivo reference standards. Osteoarthritis Cartilage 2016; 24:1012-20. [PMID: 26851449 DOI: 10.1016/j.joca.2016.01.137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 12/24/2015] [Accepted: 01/19/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Recently, computed tomography arthrography (CTa) was introduced as quantitative imaging biomarker to estimate cartilage sulphated glycosaminoglycan (sGAG) content in human cadaveric knees. Our aim was to assess the correlation between in vivo CTa in human osteoarthritis (OA) knees and ex vivo reference standards for sGAG and collagen content. DESIGN In this prospective observational study 11 knee OA patients underwent CTa before total knee replacement (TKR). Cartilage X-ray attenuation was determined in six cartilage regions. Femoral and tibial cartilage specimens harvested during TKR were re-scanned using equilibrium partitioning of an ionic contrast agent with micro-CT (EPIC-μCT), which served as reference standard for sGAG. Next, cartilage sGAG and collagen content were determined using dimethylmethylene blue (DMMB) and hydroxyproline assays. The correlation between CTa X-ray attenuation, EPIC-μCT X-ray attenuation, sGAG content and collagen content was assessed. RESULTS CTa X-ray attenuation correlated well with EPIC-μCT (r = 0.76, 95% credibility interval (95%CI) 0.64 to 0.85). CTa correlated moderately with the DMMB assay (sGAG content) (r = -0.66, 95%CI -0.87 to -0.49) and to lesser extent with the hydroxyproline assay (collagen content) (r = -0.56, 95%CI -0.70 to -0.36). CONCLUSIONS Outcomes of in vivo CTa in human OA knees correlate well with sGAG content. Outcomes of CTa also slightly correlate with cartilage collagen content. Since outcomes of CTa are mainly sGAG dependent and despite the fact that further validation using hyaline cartilage of other joints with different biochemical composition should be conducted, CTa may be suitable as quantitative imaging biomarker to estimate cartilage sGAG content in future clinical OA research.
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Affiliation(s)
- J van Tiel
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - M Siebelt
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - M Reijman
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - P K Bos
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - J H Waarsing
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | | | - K Nasserinejad
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - G J V M van Osch
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Otorhinolaryngology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - J A N Verhaar
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - G P Krestin
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - H Weinans
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands; Department of Orthopedics and Department of Rheumatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - E H G Oei
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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31
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Finnoff JT. The Evolution of Diagnostic and Interventional Ultrasound in Sports Medicine. PM R 2016; 8:S133-8. [DOI: 10.1016/j.pmrj.2015.09.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Jonathan T. Finnoff
- Department of Physical Medicine and Rehabilitation, Mayo Clinic School of Medicine, 600 Hennepin Ave, #310, Rochester, MN 55403
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32
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Ponction et infiltration articulaire du genou. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0616-1] [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]
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Telikicherla M, Kamath SU. Accuracy of Needle Placement into the Intra-Articular Space of the Knee in Osteoarthritis Patients for Viscosupplementation. J Clin Diagn Res 2016; 10:RC15-7. [PMID: 27042542 DOI: 10.7860/jcdr/2016/17127.7275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Knee osteoarthritis is characterized by inflammation in the intra-articular space or synovial membrane, breakdown of articular cartilage, and sclerosis of the subchondral bone. Intra-articular injections of Sodium hyaluronate which have viscoelastic and protective effect on articular cartilage and restores normal articular homeostasis. The efficacy of these injections is diminished when they are placed inadvertently outside the joint. For the maximum benefit, injection of hyaluronic acid derivatives needs to be placed accurately into the knee joint. AIM The study was performed to know the correct placement of needle inside the knee joint prior to Viscosupplementation by fluoroscopy using a contrast material. MATERIALS AND METHODS The accurate placement of needle was evaluated in a prospective series of 94 consecutive injections in patients without clinical knee effusion. All the injections were performed by single orthopaedic surgeon using a 5 cm 21-gauge needle through anterolateral, and lateral midpatellar portals. The needle placement in the knee joint was confirmed with fluoroscopy using the contrast material. RESULTS The accuracy rates through Lateral midpatellar and Anterolateral portals were lower than expected rate (100%). A total of 43 out of 47 injections were intra-articular, indicating accuracy of 91.5% through lateral midpatellar portal, 41 out of 47 injections were intra-articular through anterolateral portal with accuracy of 87.4%. CONCLUSION Study showed that the accuracy of needle placement was higher through Lateral midpatellar than the Anterolateral portal.
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Affiliation(s)
- Manaswini Telikicherla
- Student, Kasturba Medical College Hospital , Attavar, Mangalore, Manipal University, Manipal, Karnataka, India
| | - Surendra Umesh Kamath
- Professor and Head, Department of Orthopaedics, Kasturba Medical College Hospital , Attavar, Mangalore, Manipal University, Manipal, Karnataka, India
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34
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Temporomandibular joint disorders treated with articular injection: the effectiveness of plasma rich in growth factors-Endoret. J Craniofac Surg 2016; 26:709-13. [PMID: 25974777 DOI: 10.1097/scs.0000000000001534] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The objective of this study was to evaluate the effectiveness of the temporomandibular joint (TMJ) osteoarthritis treatment through articular injections of plasma rich in growth factors (PGRF)-Endoret. Thirteen patients (median age, 47.64 y; SD, 7.51; range, 40-64 y; male-female ratio, 2:11) with osteoarthritis of TMJ associated to chronic pain have been selected. They were treated with articular injections of PRGF-Endoret, measuring the maximum mouth opening and pain level before the first injection (t0), 30 days after just before the second (t1), and after 6 months (t2). Data were analyzed using the paired Student's t-test data. The visual analogue scale score at t0 is 7.69 (range, 4-10; SD, 1.9), whereas that at t1 is 1.54 (range, 0-5; SD, 1.74) and that at t2 is 0.23 (range, 0-2; SD, 0.65). These differences in the results are statistically highly significant (P < 0.0001 comparison t0-t1 and t0-t2 and P < 0.01 comparison t1-t2). In terms of maximum mouth opening, it reduced from 30.15 mm at t0 (range, 26-40 mm; SD, 4.44) to 37.54 mm at t1 (range, 31-51 mm; SD, 5.10), with an increase of 7.38 mm (range, 4-11 mm; SD, 2.02) and a highly significant difference (P < 0.0001). At t2, it was 39.54 mm (range, 34-51; SD, 4.55) with an increase of 9.38 mm (range, 5-12 mm; SD, 2.21) compared with t0 and that of 2.00 mm compared with t1. Both differences in the results are statistically significant (P < 0.0001 and P < 0.01, respectively). The articular injections of PRGF-Endoret represent a very efficient method to control pain and to improve the TMJ mobility.
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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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Lee SY, Gn KK, Chung BJ, Lee SW, Kim TK. Anterolateral Portal Is Less Painful than Superolateral Portal in Knee Intra-Articular Injection. Knee Surg Relat Res 2015; 27:228-32. [PMID: 26676089 PMCID: PMC4678243 DOI: 10.5792/ksrr.2015.27.4.228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/13/2015] [Indexed: 12/03/2022] Open
Abstract
Purpose Intra-articular knee injections are commonly performed in clinical practice for treating various knee joint disorders such as osteoarthritis and rheumatoid arthritis. When selecting the portal for injection, not only intra-articular needle accuracy but also procedural pain should be taken into consideration. The purpose of this study was to determine whether injection through anterolateral portal provokes less pain and provides better pain relief compared to superolateral portal. Materials and Methods A total of 60 patients with primary osteoarthritis of the knee receiving intra-articular injections were randomized into 2 groups according to the type of portal approach; anterolateral or superolateral. All patients received hyaluronic acid (20 mg) and triamcinolone (40 mg) as the first injection followed by second and third injections of hyaluronic acid on a weekly basis. Underlying knee pain, procedural pain, and knee pain at 4 weeks were evaluated using visual analogue scale (VAS). Results Injection through anterolateral portal provoked less pain (VAS, 1.5±1.3) than the superolateral portal (VAS, 1.5 vs. 2.7; p=0.004). No differences were found in the degree of pain relief at weeks between the two groups (p=0.517). Conclusions We recommend the use of anterolateral portal for intra-articular knee injection as it provokes less pain and comparably short-term pain relief than the superolateral portal.
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Affiliation(s)
- Sung Yup Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kiran Kumar Gn
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung June Chung
- Joint Reconstruction Center, Knee and Spine Hospital, Seoul, Korea
| | - Sang Wook Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae Kyun Kim
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Wagner BS, Howe AS, Dexter WW, Hatzenbuehler JR, Holt C, Haskins AE, Lucas FL. Tolerability and Efficacy of 3 Approaches to Intra-articular Corticosteroid Injections of the Knee for Osteoarthritis: A Randomized Controlled Trial. Orthop J Sports Med 2015; 3:2325967115600687. [PMID: 26535393 PMCID: PMC4622310 DOI: 10.1177/2325967115600687] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Several studies have been performed suggesting that a superolateral approach to cortisone injections for symptomatic osteoarthritis of the knee is more accurate than anteromedial or anterolateral approaches, but there are little data to correlate clinical outcomes with these results. Additionally, there are minimal data to evaluate the pain of such procedures, and this consideration may impact physician preferences for a preferred approach to knee injection. PURPOSE To determine the comparative efficacy and tolerability (patient comfort) of landmark-guided cortisone injections at 3 commonly used portals into the arthritic knee without effusion. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Adult, English-speaking patients presenting to a sports medicine clinic with knee pain attributed to radiographically proven grades I through III knee osteoarthritis were randomized to receive a cortisone injection via superolateral, anteromedial, or anterolateral approaches. Patients used a visual analog scale (VAS) to self-report comfort with the procedure. Western Ontario and McMaster Universities Arthritis Index (WOMAC) 3.1 VAS scores were used to establish baseline pain and dysfunction prior to the injection and at 1 and 4 weeks follow-up via mail. RESULTS A total of 55 knees from 53 patients were randomized for injection using a superolateral approach (17 knees), an anteromedial approach (20 knees), and an anterolateral approach (18 knees). The mean VAS scores for procedural discomfort showed no significant differences between groups (superolateral, 39.1 ± 28.5; anteromedial, 32.9 ± 31.5; anterolateral, 33.1 ± 26.6; P = .78). WOMAC scores at baseline were similar between groups as well (superolateral, 1051 ± 686; anteromedial, 1450 ± 573; anterolateral, 1378 ± 673; P = .18). The WOMAC scores decreased at 1 and 4 weeks for all groups, with no significant differences in reduction between the 3 groups. CONCLUSION Other studies have shown that the superolateral portal is the most accurate. This study did not assess accuracy, but it showed that all 3 knee injection sites studied have similar overall clinical benefit at 4-week follow-up. Procedural pain was not significantly different between groups.
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Affiliation(s)
| | | | | | | | - Christina Holt
- Department of Family Medicine, Maine Medical Center, Portland, Maine, USA
| | - Amy E Haskins
- Department of Family Medicine, Maine Medical Center, Portland, Maine, USA
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine, USA
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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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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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Where and how to inject the knee--a systematic review. Semin Arthritis Rheum 2014; 43:195-203. [PMID: 24157093 PMCID: PMC3820023 DOI: 10.1016/j.semarthrit.2013.04.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 04/15/2013] [Accepted: 04/19/2013] [Indexed: 11/28/2022]
Abstract
Objectives The knee can be injected at different anatomic sites with or without image-guidance. We undertook a systematic review to determine the accuracy of intra-articular knee injection (IAKI) and whether this varied by site, use of image-guidance, and experience of injectors, and whether accuracy of injection, site, or use of image-guidance influenced outcomes following IAKIs. Methods Medline, Embase, AMED, CINAHL, Web of Knowledge, Cochrane Central Registers for Controlled Trials up to Dec 2012 were searched for studies that evaluated either accuracy of IAKIs or outcomes related to accuracy, knee injection sites, or use of image-guidance. Within-study and between-study analyses were performed. Results Data from 23 publications were included. Within-study analyses suggested IAKIs at the superomedial patellar, medial midpatellar (MMP), superolateral patellar (SLP) and lateral suprapatellar bursae sites were more accurate when using image-guidance than when blinded (ranges of pooled risk difference 0.09–0.19). Pooling data across studies suggested blinded IAKIs at the SLP site were most accurate (87%) while MMP (64%) and anterolateral joint line (ALJL) sites were (70%) least accurate. Overall about one in five blinded IAKIs were inaccurate. There was some evidence that experience of the injector was linked with improved accuracy for blinded though not image-guided injections. Based on a small number of studies, short but not longer-term outcomes for ultrasound-guided were found to be superior to blinded IAKIs. Conclusions Image-guided IAKIs are modestly more accurate than blinded IAKIs especially at the MMP and ALJL sites. Blinded injections at SLP site had good accuracy especially if performed by experienced injectors. Further studies are required to address the question whether accurate localization is linked with an improved response.
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Douglas RJ. Aspiration and injection of the knee joint: approach portal. Knee Surg Relat Res 2014; 26:1-6. [PMID: 24639940 PMCID: PMC3953519 DOI: 10.5792/ksrr.2014.26.1.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 12/01/2013] [Accepted: 12/05/2013] [Indexed: 01/12/2023] Open
Abstract
Aspiration and injection of the knee joint is a commonly performed medical procedure. Injection of corticosteroid for the treatment of osteoarthritis is the most common reason for knee joint injection, and is performed as an office procedure. Debate exists among practitioners as to the 'best' approach portal for knee injection. This paper examines the various approach portals for injection and/or aspiration of the knee joint, as well as the accuracy of each approach. Searches were made of electronic databases, and appropriate papers were identified and hand-searched. Although there is some evidence that particular approach portals may be more efficacious in the presence of specific knee joint pathologies, generally, in experienced hands, it is of no clinical consequence as to which approach portal is utilised for aspiration or injection of the knee joint. No approach portal is 100% accurate, and the accuracy of injection of the knee joint may be enhanced by the use of techniques such as ultrasound. Practitioners are reminded that they should continuously refine and practice their preferred technique. Knee joint aspiration and injection is a common, simple, and generally safe office procedure.
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Ikeuchi M, Izumi M, Aso K, Sugimura N, Tani T. Clinical characteristics of pain originating from intra-articular structures of the knee joint in patients with medial knee osteoarthritis. SPRINGERPLUS 2013; 2:628. [PMID: 24386615 PMCID: PMC3877413 DOI: 10.1186/2193-1801-2-628] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 11/18/2013] [Indexed: 01/06/2023]
Abstract
Purpose Although disease progression of osteoarthritis has been well documented, pain pathophysiology is largely unknown. This study was designed with two purposes: 1) to characterize patients with knee pain predominantly originating from intra-articular structures and 2) to describe the location and pattern of their pain. Materials and methods 103 patients with medial knee osteoarthritis underwent an intra-articular injection of local anesthetics (joint block). At least 70% pain relief was defined as positive for the joint block, while less than 50% as negative. Pain characteristics in patients positive for joint block were evaluated in detail using a knee pain map. Results Sixty three knees (61%) were positive and 33 knees (32%) were negative. Patients negative for the joint block were significantly higher age, suffered for longer time, and complained more diffuse pain. Although pain at anterior medial area during walk was the most common finding, pain characteristics differed among different knee areas. Conclusion The characteristics of joint pain are widely variable even in patients with similar radiological features. Extra-articular sources are not negligible especially in older patients with a long history of diffuse pain. Differences in pain characteristics among knee areas should be taken into account when examining the pain source.
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Affiliation(s)
- Masahiko Ikeuchi
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505 Japan
| | - Masashi Izumi
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505 Japan
| | - Koji Aso
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505 Japan
| | - Natsuki Sugimura
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505 Japan
| | - Toshikazu Tani
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505 Japan
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van Tiel J, Reijman M, Bos PK, Hermans J, van Buul GM, Bron EE, Klein S, Verhaar JAN, Krestin GP, Bierma-Zeinstra SMA, Weinans H, Kotek G, Oei EHG. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) shows no change in cartilage structural composition after viscosupplementation in patients with early-stage knee osteoarthritis. PLoS One 2013; 8:e79785. [PMID: 24223194 PMCID: PMC3819245 DOI: 10.1371/journal.pone.0079785] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/25/2013] [Indexed: 12/11/2022] Open
Abstract
Introduction Viscosupplementation with hyaluronic acid (HA) of osteoarthritic (OA) knee joints has a well-established positive effect on clinical symptoms. This effect, however, is only temporary and the working mechanism of HA injections is not clear. It was suggested that HA might have disease modifying properties because of its beneficial effect on cartilage sulphated glycosaminoglycan (sGAG) content. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) is a highly reproducible, non-invasive surrogate measure for sGAG content and hence composition of cartilage. The aim of this study was to assess whether improvement in cartilage structural composition is detected using dGEMRIC 14 weeks after 3 weekly injections with HA in patients with early-stage knee OA. Methods In 20 early-stage knee OA patients (KLG I-II), 3D dGEMRIC at 3T was acquired before and 14 weeks after 3 weekly injections with HA. To evaluate patient symptoms, the knee injury and osteoarthritis outcome score (KOOS) and a numeric rating scale (NRS) for pain were recorded. To evaluate cartilage composition, six cartilage regions in the knee were analyzed on dGEMRIC. Outcomes of dGEMRIC, KOOS and NRS before and after HA were compared using paired t-testing. Since we performed multiple t-tests, we applied a Bonferroni-Holm correction to determine statistical significance for these analyses. Results All KOOS subscales (‘pain’, ‘symptoms’, ‘daily activities’, ‘sports’ and ’quality of life’) and the NRS pain improved significantly 14 weeks after Viscosupplementation with HA. Outcomes of dGEMRIC did not change significantly after HA compared to baseline in any of the cartilage regions analyzed in the knee. Conclusions Our results confirm previous findings reported in the literature, showing persisting improvement in symptomatic outcome measures in early-stage knee OA patients 14 weeks after Viscosupplementation. Outcomes of dGEMRIC, however, did not change after Viscosupplementation, indicating no change in cartilage structural composition as an explanation for the improvement of clinical symptoms.
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Affiliation(s)
- Jasper van Tiel
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Max Reijman
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter K. Bos
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Job Hermans
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Gerben M. van Buul
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Esther E. Bron
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Medical Informatics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Stefan Klein
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Medical Informatics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jan A. N. Verhaar
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Gabriel P. Krestin
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sita M. A. Bierma-Zeinstra
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Harrie Weinans
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Gyula Kotek
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Edwin H. G. Oei
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- * E-mail:
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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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