Musculoskeletal injection

Local treatment of pain in Tietze syndrome: A single-center experience

Background

In this study, we present our experiences with local injections of triamcinolone and prilocaine in patients diagnosed with Tietze syndrome.

Methods

Between January 2016 and January 2019, a total of 28 patients (12 males, 16 females; median age: 33 years; range, 21 to 51 years) who were diagnosed with TS in our clinic were retrospectively analyzed. Triamcinolone hexacetonide and prilocaine hydrochloride were injected into painful joints. At first week, pain sensation of the patients was recorded using the Pain Rating Scale developed by the British Pain Society. Pain was also assessed at one, two, and three weeks after injections qualitatively and based on physical examination.

Results

At one week, the pain severity before the local injection treatment was above average the pain-related discomfort rates, and the response was quite favorable after the treatment (p=0.005 and p=0.001, respectively). A statistically significant rating was observed for treatment response and success (p=0.003). Totally 75% of the patients experienced more than 70% reduction in pain level after the injection.

Conclusion

Our treatment approach involving injection of a mixture of steroid and a local anesthetic provides a rapid relief from pain, irrespective of age, sex, or employment status in patients diagnosed with Tietze syndrome.

An educational study to investigate the efficacy of three training methods for infiltration techniques on self-efficacy and skills of trainees in general practice

Background

Research shows that few general practitioners perform intra- and periarticular infiltrations. Lack of good training strategies to teach these skills would be an important reason for this observation. In this study, we investigated and compared three different training strategies for infiltrations of the glenohumeral joint, subacromial space, lateral epicondyle, carpal tunnel and knee joint.

Methods

Trainees in general practice were randomized into three teaching groups: a theoretical lecture (n = 18), or a theoretical lecture with training on anatomical models (n = 19) or with a training on cadavers (n = 11). The study period was 3 months. Before and after the training, the self-efficacy (questionnaire) and skills (Objective Structured Clinical Examination or OSCE, test on anatomical models) were evaluated. The self-efficacy was assessed again 3 months later. A Kruskal-Wallis test was used to compare the results before versus after training and between groups (p < 0.05).

Results

All three training strategies had a significantly positive effect on the self-efficacy concerning knowledge and skills. This benefit remained 3 months after training. However, some participants still felt uncomfortable to perform infiltrations. Best scores for self-efficacy concerning skills and best scores on the OSCE were observed after training on cadavers, followed by training on anatomical models.

Conclusions

Based on this study we suggest the combination of a theoretical lecture with a training on cadavers to teach infiltration techniques. To achieve an optimal long-term effect, additional refresher trainings may be necessary.

Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain

BACKGROUND

The diagnosis of subacromial pathology is limited by the poor accuracy of clinical tests for specific pathologies. The aim of this study was to estimate the diagnostic accuracy of clinical examination and imaging features for identifying subacromial pain (SAP) defined by a positive response to diagnostic injection, and to evaluate the influence of imaging findings on the clinical diagnosis of SAP.

METHODS AND FINDINGS

In a prospective, diagnostic accuracy design, 208 consecutive patients presenting to their primary healthcare practitioner for the first time with a new episode of shoulder pain were recruited. All participants underwent a standardized clinical examination, shoulder x-ray series and diagnostic ultrasound scan. Results were compared with the response to a diagnostic block of xylocaineTM injected into the SAB under ultrasound guidance using ≥80% post-injection reduction in pain intensity as the positive anaesthetic response (PAR) criterion. Diagnostic accuracy statistics were calculated for combinations of clinical and imaging variables demonstrating the highest likelihood of a PAR. A PAR was reported by 34% of participants. In participants with no loss of passive external rotation, combinations of three clinical variables (anterior shoulder pain, strain injury, absence of symptoms at end-range external rotation (in abduction)) demonstrated 100% specificity for a PAR when all three were positive (LR+ infinity; 95%CI 2.9, infinity). A full-thickness supraspinatus tear on ultrasound increased the likelihood of a PAR irrespective of age (specificity 98% (95%CI 94, 100); LR+ 6.2; 95% CI 1.5, 25.7)). Imaging did not improve the ability to rule-out a PAR.

CONCLUSION

Combinations of clinical examination findings and a full-thickness supraspinatus tear on ultrasound scan can help confirm, but not exclude, the presence of subacromial pain. Other imaging findings were of limited value for diagnosing SAP.

Effectiveness of an Interprofessional and Multidisciplinary Musculoskeletal Training Program

BACKGROUND

Musculoskeletal (MSK) problems are common, and a recent US Bone and Joint Initiative calls for new models of education and professional collaboration. Evidence of feasibility and acceptability of innovative methods are needed.

OBJECTIVE

We assessed if an experimental immersion interdisciplinary MSK curriculum would be acceptable to residents from different specialties, be feasible within existing rotations, and be effective in strengthening clinical skills.

METHODS

Through funding from the Veterans Affairs Office of Academic Affiliations and the Office of Specialty Care, we developed a Center of Excellence in MSK Care and Education. A core element is the monthly MSK Education Week, which teaches skills and provides opportunities to apply these in clinical settings. Participants include internal medicine, physical medicine and rehabilitation, and orthopaedic surgery residents, as well as students and residents from other health professions programs. All were assigned to the MSK week in lieu of other clinical experiences. Faculty encompassed primary care, rheumatology, endocrinology, orthopaedics, and physical medicine and rehabilitation. Assessments include surveys and a 2-station objective structured clinical examination (OSCE).

RESULTS

Since 2012, a total of 176 trainees have participated. Percentage of trainees reporting ability to evaluate and manage MSK complaints increased (9% to 87% for shoulder; 18% to 86% for knee), and confidence performing MSK injections increased from 10% to 70%. Competency in evaluation of shoulder and knee pain was confirmed by OSCEs.

CONCLUSIONS

The MSK week program was accepted by residents from the 3 specialties, with learners reporting improved ability to perform shoulder and knee examinations, as demonstrated by OSCEs.

Perspectives in ultrasound-guided musculoskeletal interventions

Ultrasonography (USG) is a safe, easily available, and cost-effective modality, which has the additional advantage of being real time for imaging and image-guided interventions of the musculoskeletal system. Musculoskeletal interventions are gaining popularity in sports and rehabilitation for rapid healing of muscle and tendon injuries in professional athletes, healing of chronic tendinopathies, aspiration of joint effusions, periarticular bursae and ganglia, and perineural injections in acute and chronic pain syndromes. This article aims to provide an overview of the spectrum of musculoskeletal interventions that can be done under USG guidance both for diagnostic and therapeutic purposes.

Current perspectives in stem cell research for knee cartilage repair

Protocols based on the delivery of stem cells are currently applied in patients, showing encouraging results for the treatment of articular cartilage lesions (focal defects, osteoarthritis). Yet, restoration of a fully functional cartilage surface (native structural organization and mechanical functions) especially in the knee joint has not been reported to date, showing the need for improved designs of clinical trials. Various sources of progenitor cells are now available, originating from adult tissues but also from embryonic or reprogrammed tissues, most of which have already been evaluated for their chondrogenic potential in culture and for their reparative properties in vivo upon implantation in relevant animal models of cartilage lesions. Nevertheless, particular attention will be needed regarding their safe clinical use and their potential to form a cartilaginous repair tissue of proper quality and functionality in the patient. Possible improvements may reside in the use of biological supplements in accordance with regulations, while some challenges remain in establishing standardized, effective procedures in the clinics.

Steroid psychosis: a review for neurosurgeons

Steroids are beneficial in neurological illness, but have many serious side effects. Having observed several patients with severe steroid psychoses, which greatly prolonged their hospitalizations, the authors sought to improve understanding of this entity. A literature review was conducted. The incidence of severe psychiatric symptoms was estimated in a meta-analysis of 2,555 patients to be 5.7 % and the incidence of any psychiatric symptoms was 18.6 % in patients receiving >80 mg/day of prednisone (12 mg/day dexamethasone). Dose is not predictive of time of onset, severity, type, or duration of symptoms. Symptoms can develop rapidly following exposure to even low doses and with oral, epidural, or intra-articular administration. Glucocorticoid effects on the brain fall into three categories: genomic, non-genomic, and neurotrophic/neurotoxic and can be permanent. Excessive glucocorticoid exposure may result in decreased production of endogenous neurosteroid molecules, resulting in unopposed glucocorticoid effects. Treatment includes early recognition, steroid withdrawal when appropriate, reduction in stimulation, and medication. Atypical antipsychotics like olanzapine and risperidone may cause fewer dystonic reactions and extrapyramidal symptoms than typical antipsychotics like haloperidol, and therefore, are often recommended as first line treatment. Steroids are powerful medications with many undesirable side effects. They should be used with caution. More research is needed on their effects on the human central nervous system.

Distribution of effusion in knee arthritis as measured by high-resolution ultrasound

Information about the distribution of effusion within the arthritic knee joint should be considered in selecting an anatomical approach for arthrocentesis. We recorded ultrasound measurements of fluid distribution in the knees of patients attending our clinic for knee injections under ultrasound guidance. In a cross-sectional observational study, we used high-resolution ultrasound (US) to record measurements of maximum fluid depth in the medial, midline and lateral regions of the suprapatellar pouch (SPP) in 46 patients with arthritis attending for routine US-guided injection of the knee. Mean fluid depth [in millimetres, (SD)] was significantly greater in the lateral SPP [9.2 (5.1)] than in the medial [6.5 (4.6)] or the midline [5.9 (3.7)] regions with the knee in relaxed full extension (p < 0.001 for comparison of lateral SPP with both midline and medial SPP). Small effusions were more commonly detected in the lateral SPP than elsewhere. In patients with painful knee arthritis, fluid distributes maximally to the lateral SPP in the extended knee. This has implications regarding the anatomical approach to arthrocentesis that clinicians should choose to perform and teach.

The efficacy, accuracy and complications of corticosteroid injections of the knee joint

PURPOSE

Corticosteroid knee injections are being increasingly used in the conservative management of knee osteoarthritis. The procedure is usually performed in secondary care by orthopaedic surgeons and rheumatologists, but as the role of general practitioners in chronic disease management expands, joint injections are now frequently being performed in primary care. It is commonly perceived amongst clinicians that the benefits of corticosteroid knee joint injections in treating symptomatic knee osteoarthritis significantly outweigh the risks of complications.

METHODS

The evidence in the literature for the benefits, accuracy, safety and complications of corticosteroid knee injections in osteoarthritis is reviewed. The perception that serious complications are rare is addressed, and the incidence of infectious complications is estimated.

RESULTS AND CONCLUSIONS

Short-term symptomatic relief is the only evidence-based benefit of corticosteroid injection of an osteoarthritic knee. Accurate intra-articular placement is not achieved in up to 20% of injections and varies considerably with the anatomical approach used. There is no evidence that a medial approach is more accurate. The incidence of serious infectious complications following knee joint injections ranges widely, and may be as high as 1 in 3,000 and potentially far higher in high-risk patients for whom specialist management is advised.