Ultrasound-guided therapeutic procedures in the musculoskeletal system

Immediate Effects of Long-Axis Talocrural Thrust Manipulation on the Length of the Anterior Talofibular and Calcaneofibular Ligaments Measured With Musculoskeletal Ultrasound Imaging

OBJECTIVE

The aim of the present study was to measure the immediate effect of a thrust manipulation on the length of the anterior talofibular and calcaneofibular ligaments in healthy patients.

METHODS

A convenience sample of 47 healthy patients were recruited for this quasi-experimental study. The patients had an age range from 22 to 54 years, with a mean age of 30.36 years. There were 23 female patients and 24 male patients. Musculoskeletal ultrasound imaging was used to measure the length of the anterior talofibular and calcaneofibular ligaments before and immediately after a high-velocity long-axis thrust manipulation of the talocrural joint during various validated test positions.

RESULTS

A single long-axis thrust manipulation did not result in a significant change in the length of the anterior talofibular ligament (P = .325). Additionally, there was no significant difference in calcaneofibular length after a long-axis thrust manipulation (P = .26).

CONCLUSION

The results indicate that the length of the anterior talofibular and calcaneofibular ligament did not significantly change after a single long-axis thrust manipulation of the talocrural joint in healthy patients. It appears that the joint capsule of the talocrural joint reached end-range during the manipulation before the ligament undergoes plastic length changes; thus, the increase in joint range of motion after a thrust manipulation was probably not due to increased plastic length changes of the anterior talofibular and calcaneofibular ligaments.

Urgent ultrasound-guided interventional procedures

Interventional radiology procedures have become a fundamental part of radiology, resulting in faster diagnoses and in safer, more effective, and more precise treatments, all of which are important, and even more so when referring to urgent situations, where time is of the essence. In this context, the use of ultrasound to guide interventional procedures enables real-time viewing in multiple planes that can be done at the patient's bedside, which is a great advantage in critical patients. We review the indications and technical aspects of the most common procedures related with radiological care of urgent patients.

Bedside ultrasound-guided aspiration and corticosteroid injection of a baker's cyst in a patient with osteoarthritis and recurrent knee pain

Baker's cyst accompanying knee osteoarthritis represents a common cause of knee pain presenting to the emergency department. In this case report, a 56-year-old male presented with atraumatic left knee pain and swelling. Radiographically, he had tricompartmental osteoarthritis and was found to have a baker's cyst on duplex ultrasound. Using point-of-care ultrasound, the cyst was aspirated and corticosteroids were injected. The patient tolerated the procedure well and was discharged with a compression wrap and orthopedic follow-up. Baker's cyst aspiration with corticosteroid injection represents a safe alternative treatment option for patients. In some cases, this treatment may be definitive. Orthopedists currently use this procedure to reduce pain and improve function for patients with chronic knee ailments related to baker's cysts. As demonstrated in this case report, implementing this bedside procedure in the emergency department with orthopedic follow-up expands non-surgical, non-narcotic treatment options for patients with chronic knee pain secondary to Baker's cysts with osteoarthritis.

Low-Dose Pre-Operative Botulinum Toxin A Effectively Facilitates Complex Ventral Hernia Repair: A Case Report and Review of the Literature

Background: Complex ventral hernias following laparotomy present a unique challenge in that repair is hindered by the lateral tension of the abdominal wall. A novel approach to overcome this is the “chemical component separation” technique. Here, botulinum toxin A (BTA) is instilled into the muscles of the abdominal wall. This induces flaccid paralysis and effectively reduces tension in the wall, allowing the muscles to be successfully joined in the midline during surgery. We describe a method where a large incisional hernia was repaired using this technique and review the variations in methodology. Case report: A woman in her mid-40s developed a ventral hernia in the setting of a previous laparotomy for a small bowel perforation. Computed tomography (CT) of the abdomen demonstrated an 85 (Width) × 95 mm (Length) ventral hernia containing loops of the bowel. Pre-operative botulinum toxin A administration was arranged at the local interventional radiology department. A total of 100 units of BTA were instilled at four sites into the muscular layers of the abdominal wall under CT-fluoroscopic guidance. She underwent an open incisional hernia repair 4 weeks later, where the contents were reduced and the abdominal wall layers were successfully joined in the midline. There was no clinical evidence of hernia recurrence at 3-months follow-up. Conclusion: Low-dose BTA effectively facilitates the surgical management of large ventral incisional hernias. There is, however, significant variation in the dosage, concentration and anatomical landmarks in which BTA is administered as described in the literature. Further studies are needed to assess and optimise these variables.

Evaluation of anterotalofibular and calcaneofibular ligament stress tests utilizing musculoskeletal ultrasound imaging

Study Design: A quasi-experimentalBackground: The talar tilt test and the anterior drawer test are clinically used to evaluate the length of the anterotalofibular (ATFL) and calcaneofibular (CFL) ligaments. Based on the current literature, there is no clear diagnostic utility or preference for either test. This study investigated ligament lengthening during these special tests and compared the talar tilt test to the long axis distraction test for the CFL length.Methods: A convenience sample of 47 healthy subjects were recruited for this study. Musculoskeletal ultrasound imaging (MSK US) was used to measure the length of the ATFL and CFL during the talar tilt and anterior drawer tests. Additionally, CFL lengthening during the talar tilt was compared to the long axis distraction test.Outcomes: A significant difference was found (p < .001) in ATFL length between the talar tilt and anterior drawer test. This indicates that the talar tilt test is preferred to maximally lengthen the ATFL. There was a significant difference in CFL length (p < .001) between the talar tilt test and the long axis distraction test.Discussion: The results of this study identified that the talar tilt test resulted in more ATFL lengthening than the anterior drawer test and thus is the preferred test to assess ligament length. Additionally, both the long axis distraction test and the talar tilt test cause lengthening of the CFL. Therefore, the long axis distraction test can be used as a differentiation test to determine if either the ATFL or the CFL is the structure with increased laxity.

Iliopsoas hematomas in people with hemophilia: diagnosis and treatment

INTRODUCTION

Iliopsoas muscle hemorrhage in patients with hemophilia is a serious complication with relevant related morbidity.

AREAS COVERED

A Cochrane Library and PubMed (MEDLINE) search of studies related to iliopsoas hematomas in hemophilia was analyzed. Pain in the hip joint area and femoral nerve involvement in people with hemophilia should alert physicians to the likelihood of a hemorrhage of the iliopsoas muscle. Clinically, reduced hip range of motion and deficient motor and sensory function of the femoral nerve can be found. Imaging studies, such as ultrasonography (US), CT scan, and MRI will confirm the diagnosis. The first-line therapy for iliopsoas hematoma must be conservative (hematological treatment using high-dose replacement therapy until full resorption monitored by means of imaging studies). Related femoral nerve involvement typically resolves with conservative treatment (rehabilitation). Pelvic hemophilic pseudotumors can occur in patients with hemophilia due to recurrent iliopsoas muscle bleeding, often related to late diagnosis and poor hemostasis.

EXPERT OPINION

Long-term clotting factor replacement is the pillar of the management of iliopsoas hematomas. Percutaneous US-guided aspiration of blood can be performed in hematomas of large size. However, the rate of failed aspirations and hematoma repetition is substantial (13%).

Musculoskeletal ultrasound imaging and clinical reasoning in the management of a patient with cervicogenic headache: a case report

Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause-effect relationship between the treatment and positive outcomes in this case report has to be further validated.

Subclinical crystal arthropathy: a silent contributor to inflammation and functional disability in knees with osteoarthritis-an ultrasound study

PURPOSE

This study aimed at investigating the prevalence of crystal deposits with knee osteoarthritis (OA) by ultrasonography and measure the inflammatory burden associated with crystal deposits in OA using WOMAC score.

METHODS

Adult patients with primary knee OA diagnosed according to the American College of Rheumatology criteria were included. Participants were subjected to history taking, clinical examination, knee US, and plain radiography. The EULAR and the OMERACT ultrasonography definitions and scanning protocols were used.

RESULTS

Fifty-three patients (44 females, 9 males) were enrolled. Mean values were 53.5 years ± 8.3 SD for age and 42.5 months ± 49.5 SD for disease duration. Crystals were detected by US in 73/106 knees (68.9%). Plain radiography revealed chondrocalcinosis in three patients. Mean values for WOMAC pain, stiffness, and disability scores were 14.38 ± 3.99, 4.93 ± 2.06, and 49.61 ± 13.06, respectively, with insignificant differences relative to presence of crystals (P > 0.05). Regression analysis revealed a 4.1-fold increase in the incidence of sonographic crystals with bursitis (OR = 4.13, CI = 1.5-11.2, p = 0.01) and a 3.2-fold increase in the incidence of sonographic crystals with synovial effusion (OR = 3.16, CI = 1.34-7.44, p = 0.01).

CONCLUSION

Subclinical crystals were detected in a considerable number of patients with primary knee OA. The incidence of crystal deposits was significantly higher in patients with bursitis and knee effusion.

Calcifying Tendinitis of Shoulder: A Concise Review

Calcifying Tendinitis (CT) shoulder a self limiting disorder characterized by deposition of calcium salts in rotator cuff muscles. The main symptom being pain followed by activity restriction resolving on its own in most cases. Symptomatic patients are initially managed by NSAIDs, Physiotherapy, Corticosteroid injections. ESWT involves acoustic waves causing fragmentation of deposits with pain releif. Ultrasound guided needling barbotage have shown promising results. Arthroscopic excision remains the definitive management for patients associated with complications as cuff tear and for uncomplicated patients. In calcifying tendinitis the initial evaluation, maintenance of function and appropriate choice of treatment modalities determines the prognosis.

Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management

Symptomatic scapulothoracic disorders, including scapulothoracic crepitus and scapulothoracic bursitis are uncommon disorders involving the scapulothoracic articulation that have the potential to cause significant patient morbidity. Scapulothoracic crepitus is the presence of a grinding or popping sound with movement of the scapula that may or may not be symptomatic, while scapulothoracic bursitis refers to inflammation of bursa within the scapulothoracic articulation. Both entities may occur either concomitantly or independently. Nonetheless, the constellation of symptoms manifested by both entities has been referred to as the snapping scapula syndrome. Various causes of scapulothoracic crepitus include bursitis, variable scapular morphology, post-surgical or post-traumatic changes, osseous and soft tissue masses, scapular dyskinesis, and postural defects. Imaging is an important adjunct to the physical examination for accurate diagnosis and appropriate treatment management. Non-operative management such as physical therapy and local injection can be effective for symptoms secondary to scapular dyskinesis or benign, non-osseous lesions. Surgical treatment is utilized for osseous lesions, or if non-operative management for bursitis has failed. Open, arthroscopic, or combined methods have been performed with good clinical outcomes.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

Chronic expanding hematoma of the left flank mimicking a soft-tissue neoplasm

Soft-tissue hematomas are a common clinical entity often associated with trauma, surgery, and bleeding disorders. In the majority of cases, soft-tissue hematomas acutely appear and spontaneously resolve, but sometimes, they present as swellings that slowly expand and progressively increase with time.

We present a case of a 70-year-old man with chronic expanding hematoma of the left flank without any history of recent trauma or other medical disease.

The diagnosis could not be confirmed on imaging features alone, so the patient was taken to surgery for open biopsy and excision.

In patients with slowly growing extremity masses without recent trauma or chronic medical disorders, the differential diagnosis becomes challenging, and chronic expanding hematoma should be considered in addition to soft-tissue sarcomas and other malignancies.

Ultrasound in Arthritis

Ultrasound is currently performed in everyday rheumatologic practice. It is used for early diagnosis, to monitor treatment results, and to diagnose remission. The spectrum of pathologies seen in arthritis with ultrasound includes early inflammatory features and associated complications. This article discusses the spectrum of ultrasound features of arthritides seen in rheumatoid arthritis and other connective tissue diseases in adults, such as Sjögren syndrome, lupus erythematosus, dermatomyositis, polymyositis, and juvenile idiopathic arthritis. Ultrasound findings in spondyloarthritis, osteoarthritis, and crystal-induced diseases are presented. Ultrasound-guided interventions in patients with arthritis are listed, and the advantages and disadvantages of ultrasound are discussed.

Anaesthetics, steroids and platelet-rich plasma (PRP) in ultrasound-guided musculoskeletal procedures

This review aims to evaluate the role of anaesthetics, steroids and platelet-rich plasma (PRP) employed with ultrasound-guided injection in the management of musculoskeletal pathology of the extremities. Ultrasound-guided injection represents an interesting and minimally invasive solution for the treatment of tendon and joint inflammatory or degenerative diseases. The availability of a variety of new drugs such as hyaluronic acid and PRP provides expansion of the indications and therapeutic possibilities. The clinical results obtained in terms of pain reduction and functional recovery suggest that the use of infiltrative procedures can be a good therapeutic alternative in degenerative and inflammatory joint diseases.

Musculoskeletal ultrasonography in routine rheumatology practice: data from Central and Eastern European countries

The main aim was to gain structured insight into the use of musculoskeletal ultrasonography (MSUS) in routine rheumatology practices in Central and Eastern European (CEE) countries. In a cross-sectional, observational, international, multicenter survey, a questionnaire was sent to investigational sites in CEE countries. Data on all subsequent routine MSUS examinations, site characteristics, MSUS equipment, and investigators were collected over 6 months or up to 100 examinations per center. A total of 95 physicians at 44 sites in 9 countries provided information on a total of 2810 MSUS examinations. The most frequent diagnoses were rheumatoid arthritis (RA) and spondyloarthritis (34.8 and 14.9 % of cases, respectively). Mean number of joints examined was 6.8. MSUS was most frequently performed for diagnostic purposes (58 %), particularly in patients with undifferentiated arthritis, suspected soft tissue disorders, or osteoarthritis (73.0–85.3 %). In RA patients, 56.3 % of examinations were conducted to monitor disease activity. Nearly all investigations (99 %) had clinical implications, while the results of 78.6 % of examinations (51.6–99.0 %) were deemed useful for patient education. This first standardized multicountry survey performed in CEEs provided a structured documentation of the routine MSUS use in participating countries. The majority of MSUS examinations were performed for diagnostic purposes, whereas one-third was conducted to monitor disease activity in RA. A majority of examinations had an impact on clinical decision making and were also found to be useful for patient education.

Effectiveness of Ultrasound Guidance on Intraarticular and Periarticular Joint Injections: Systematic Review and Meta-analysis of Randomized Trials

OBJECTIVE

The aim of this study was to evaluate the effectiveness and accuracy of ultrasound-guided intraarticular and periarticular joint injections as compared with landmark-guided injections technique.

METHODS

A systematic literature search was performed in Medline, Web of Science, Embase, the Cochrane Central Register of Controlled Trials, reference lists of articles, and other sources. Only randomized controlled trials were included. Two reviewers independently selected and assessed each study for quality and extracted data.

RESULTS

Twelve randomized controlled trials were included in the meta-analysis. The results indicated that ultrasound-guided intraarticular and periarticular joint injections were more accurate than the landmark-guided injections (odds ratio, 0.36; 95% confidence interval, 0.22-0.60). Ultrasound-guided joint injections significantly decreased the visual analog scale scores at both 2 wks (mean difference, -9.57; 95% confidence interval, -13.14 to -5.99) (P < 0.00001) and 6 wks (mean difference, -14.21; 95% confidence interval, -18.20 to -10.21) (P < 0.00001) after injection. There was no statistically significant difference in visual analog scale score at 12 wks between ultrasound-guided and landmark-guided intraarticular and periarticular joint injections (mean difference, -4.42; 95% confidence interval, -11.71 to 2.87) (P = 0.23).

CONCLUSIONS

Intraarticular and periarticular injections using ultrasound guidance significantly improves the accuracy of joint injections, and there is a significant decrease in visual analog scale scores for up to 6 wks after injection. The effect of ultrasound guidance on the long-term outcome of joint injections is inconclusive. The improved accuracy of injections was associated with pain relief. The authors recommend routine ultrasound guidance for intraarticular and periarticular injections.

Short-term efficacy to conventional blind injection versus ultrasound-guided injection of local corticosteroids in tenosynovitis in patients with inflammatory chronic arthritis: A randomized comparative study

OBJECTIVE

To compare the short-term efficacy of conventional blind injection (CBI) versus ultrasound-guided injection (USGI) of corticosteroids (CS) injection in tenosynovitis in patients with chronic arthritis and to investigate if the USGI is a less painful procedure and if there are differences in the changes of US findings during the post injection follow-up.

METHODS

Patients presenting tenosynovitis requiring CS injection were involved. After clinical and US evaluation, patients were randomized to receive CBI or USGI. Efficacy of procedure was assessed by the improvement in both Health Assessment Questionnaire (HAQ) and pain visual analogue scale (VAS), including procedure-VAS global-VAS and local-VAS, after 1 and 4 weeks post-procedure. Power Doppler (PD) and greyscale (GS) US findings were also object of the follow-up. CBI or USGI under an aseptic technique were performed according the local guidelines using 20mg of methylprednisolone acetate.

RESULTS

A total of 114 patients were randomized to receive CBI (54 patients) or USGI (60 patients) procedure. No significant difference was observed in terms of gender, age and pain duration among CBI and USGI groups at baseline. USGI proved to be significantly less painful than CBI (P=0.0001). AUC analysis showed that during the follow up visits, the USGI procedure had significantly better response in HAQ, local-VAS and global-VAS (P=0.0001, P=0.012 and P=0.0001 respectively) compared to CBI. During the follow up period, a significant greater reduction in the PD scores was found in the USGI group compared to the CBI group (P=0.0002), whereas no statistical differences were found in the GS findings between the groups (P=0.5627).

CONCLUSION

Our study demonstrates superiority of USGI over CBI for CS injections in painful tenosynovitis, having better short-term outcomes measured by functional, clinical and US scores. These data support the use of USGI for tenosynovits in typical inpatient and/or outpatient in rheumatological practices.

Treatment of Popliteal (Baker) Cysts With Ultrasound-Guided Aspiration, Fenestration, and Injection: Long-term Follow-up

Background:

The purpose of this study was to determine the efficacy of ultrasound-guided aspiration, fenestration, and injection as a treatment in patients with symptomatic popliteal cysts.

Hypothesis:

Ultrasound-guided aspiration, fenestration, and injection (UGAFI) is an effective and safe treatment option for symptomatic popliteal cysts.

Study Design:

Retrospective cohort study.

Level of Evidence:

Level 3.

Methods:

Patients who received a UGAFI of popliteal cysts from 2008 to 2011 were identified. Preaspiration (PA) and follow-up Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, cyst recurrence, complications, cyst complexity, and size were obtained and compared for statistical significance. UGAFI involved aspiration of fluid through a spinal needle, fenestration of the cyst walls and septations, and injection of 1 mL (40 mg) triamcinolone (Kenalog) and 2 mL 0.5% bupivacaine (Sensorcaine) into the decompressed remnant.

Results:

The mean PA WOMAC score (48.55) improved significantly at final follow-up (FFU) to 17.15 (P < 0.0001) for 47 patients. Within the WOMAC subcategories, there was also a significant difference in pain (PA, 10.68; FFU, 3.94; P < 0.0001), stiffness (PA, 4.51; FFU, 1.77; P < 0.0001), and physical function (PA, 31.34; FFU, 12.17; P < 0.0001). There were 6 reaspirations for recurrence (12.7%), and 1 patient underwent unicompartmental knee arthroplasty. There were no infections or other complications.

Conclusion:

Significant clinical improvement in patients with symptomatic popliteal cysts can be achieved via UGAFI as the sole treatment.

Clinical Relevance:

UGAFI is a safe and effective option as the sole treatment modality for symptomatic popliteal cysts.

Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

This randomized controlled study addressed whether sonographic needle guidance affected the outcomes of corticosteroid injection for symptomatic carpal tunnel syndrome. Seventy-seven symptomatic carpal tunnels were randomized to injection by either (1) conventional anatomic landmark palpation-guided injection or (2) sonographic image-guided injection, each using a two-step technique where 3 ml of 1% lidocaine was first injected to hydrodissect and hydrodisplace critical intra-carpal tunnel structures followed by injection with 80 mg of triamcinolone acetonide (2 ml). Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, total cost, and cost per responder were determined. There were no complications in either treatment group. Relative to conventional anatomic landmark palpation-guided methods, sonographic guidance for injection of the carpal tunnel resulted in 77.1% reduction in injection pain (p<0.01), a 63.3% reduction in pain scores at outcome (p<0.014), 93.5% increase in the responder rate (p<0.001), 84.6% reduction in the non-responder rate (p<0.001), a 71.0% increase in therapeutic duration (p<0.001), and a 59.3% ($150) reduction in cost/responder/year for a hospital outpatient (p<0.001). However, despite improved outcomes, cost per patient per year was significantly increased for an outpatient in a physician's office and was neutral for a hospital outpatient. Sonographic needle guidance significantly improves the performance and clinical outcomes of injection of the carpal tunnel and is cost-effective for a hospital-based practice, but based on current reimbursements, it significantly increases overall costs for medical care delivered in a non-hospital-based physician practice.

MRI characteristics of cysts and "cyst-like" lesions in and around the knee: what the radiologist needs to know

Objectives and Methods

A variety of benign cystic or “cyst-like” lesions may be encountered during a routine magnetic resonance imaging (MRI) of the knee. These lesions comprise a diverse group of entities from benign cysts to complications of underlying diseases. In addition, normal anatomic bursae and recesses may be misdiagnosed as an intra-articular cystic lesion when they are distended. However, the majority of the aforementioned lesions have characteristic MR appearances that allow a confident diagnosis, thus obviating the need for additional imaging or interventional procedures.

Results

This article includes a comprehensive pictorial essay of the characteristic MRI features of common and uncommon benign cysts and “cyst-like” lesions in and around the knee joint.

Discussion

For accurate assessment of the “cystic structure”, a radiologist should be able to identify typical MRI patterns that contribute in establishing the correct diagnosis and thus guiding specific therapy and avoiding unwarranted interventional procedures such as biopsy or arthroscopy.

Teaching points

• Cystic lesions are common in knee MRI and the commonest, the Baker’s cyst, has an incidence of 38 %.

• Synovial cysts, meniscal cysts, normal knee bursae and recesses have characteristic MR appearances.

• Miscellaneous “cyst-like” lesions may require a more dedicated MR protocol for a correct diagnosis.

Ultrasound-guided musculoskeletal procedures in children

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

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

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

Role of diagnostic ultrasound in the assessment of musculoskeletal diseases

The wide availability and recent improvement in technology coupled with portability, low cost and safety makes ultrasound the first choice imaging investigation for the evaluation of musculoskeletal diseases. Diagnostic use of ultrasound findings is greatly enhanced by knowledge of the clinical presentation. Conversely, ultrasound skills with its prerequisite anatomical knowledge make the clinical diagnosis more precise and reduce uncertainty in the choice of therapy. Therefore, it is essential for rheumatologists to acquire ultrasonography skills in order to improve patient care. Ultrasound examination provides an excellent opportunity for patient education and to explain the rationale for therapy. This review summarizes the indications for musculoskeletal ultrasound and describes its role in diagnosis, monitoring and prognosis.

A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee

OBJECTIVE

The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee.

METHODS

Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

RESULTS

Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction ($17) in cost per patient per year, and a 58% ($224) reduction in cost per responder per year for a hospital outpatient (P < 0.001).

CONCLUSIONS

Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.

Ultrasound guidance improves the accuracy of the acromioclavicular joint infiltration: a prospective randomized study

Degeneration of the acromioclavicular joint (AC) often causes impaired shoulder function and pain. Its infiltration results in reportedly beneficial short-term effects. Misplacement of infiltrations is observed in high numbers. A previous study showed high accuracy of infiltrations of one surgeon comparing conventional palpation technique to ultrasound guidance. This study evaluates if ultrasound-guided AC joint infiltration is feasible for therapists of different levels of experience and if the accuracy can be increased. One hundred and twenty AC joints of 60 cadavers were enrolled into a prospective, randomized observer-blinded study. Six therapists of three different levels of experience infiltrated 20 AC joints each. Half of them were infiltrated after palpation of the joint space, half of them were ultrasound-guided infiltrated. Controls were performed pre- and post-infiltration by an independent radiologist. In total, accurate infiltration was observed in 70%. In 25%, misplacement of the infiltration was recorded in the palpation-, in 2% in the ultrasound- and in 3% in both groups. The difference between the two groups was significant (P = 0.009). Ultrasound-guided infiltration to the AC joint is significantly more accurate than conventional palpation technique. This method is simple, efficient and can be applied by therapists of all levels of experience.

A Randomized Controlled Trial of the Cost-Effectiveness of Ultrasound-Guided Intraarticular Injection of Inflammatory Arthritis

Objective.

We studied whether sonographic needle guidance affected the outcomes of intraarticular (IA) injection for inflammatory arthritis.

Methods.

Joints with inflammatory arthritis (n = 244; 76% rheumatoid arthritis, 3% small joints, 51% intermediate, and 46% large) were randomized to injection by conventional palpation-guided anatomic injection (120 joints) or sonographic image-guided injection enhanced with a 1-handed reciprocating procedure device mechanical syringe (124 joints). A 1-needle, 2-syringe technique was used. After IA placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and triamcinolone acetonide was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

Results.

Relative to conventional palpation-guided methods, sonographic guidance for injection of inflammatory arthritis resulted in an 81% reduction in injection pain (p < 0.001), 35% reduction in pain scores at outcome (p < 0.02), 38% increase in the responder rate (p < 0.003), 34% reduction in the non-responder rate (p < 0.003), 32% increase in therapeutic duration (p = 0.01), 8% reduction ($7) in cost/patient/year, and a 33% ($64) reduction in cost/responder/year for a hospital outpatient (p < 0.001).

Conclusion.

Sonographic needle guidance improves the performance, clinical outcomes, and cost-effectiveness of IA injections for inflammatory arthritis. (Clinical Trial Identifier NCT00651625)

[US-guided interventional procedures: what a radiologist needs to know]

US has important advantages in guiding interventional procedures: it is economical and widely available, it does not use ionizing radiation, and it requires less time than other techniques. US guidance can be provided using devices adapted to probes or using the freehand technique (holding the needle in one hand and the probe in the other). US-guided procedures require careful planning, adequate hemostasis or a directly compressible puncture site, the patient's informed consent, and appropriate measures to ensure asepsis and anesthesia. The technique involves introducing the needle or catheter through the plane of the US slice. The advance of the needle is controlled in real time. High resolution linear probes are ideal for interventional procedures in superficial tissues, but 3.5 MHz probes are required for procedures in deep tissues. The most common procedures include biopsies, drainages, and percutaneous injections. Biopsies can be carried out using fine needles to obtain material for cytological study (fine-needle aspiration cytology) or using large needles to obtain specimens for histologic study (core biopsy). Core biopsy is more sensitive and more specific, and it has a low rate of complications. Drainage almost always involves placing a catheter in a fluid collection; it can be done using the Seldinger techniques, trocars, or pleural catheters. US-guided percutaneous injections can be used to inject substances into infectious lesions, tumors, or nerve plexuses, and they are especially useful in musculoskeletal disease.

Sonography of the coracohumeral interval: a potential technique for diagnosing coracoid impingement

OBJECTIVE

Coracoid impingement has been recognized as an etiology for anterior shoulder pain; however, no imaging reference standard exists. We used sonography to compare the coracohumeral interval (CHI) in asymptomatic volunteers with the CHI in patients with coracoid impingement.

METHODS

Bilateral shoulder sonography was performed in 19 asymptomatic volunteers (10 men and 9 women) and in 8 shoulders in 7 patients (6 men and 1 woman) with a clinical diagnosis of coracoid impingement. With the arm adducted across the chest, the interval between the coracoid process and the lesser tuberosity of the humerus was measured using a linear array ultrasound transducer with a peak frequency of 13 MHz.

RESULTS

In the asymptomatic volunteers, the mean +/- SD for the CHI was 12.2 +/- 2.5 mm (range, 7.8-17.5 mm). In the symptomatic shoulders, the mean +/- SD for the CHI was 7.9 +/- 1.4 mm (range, 5.9-9.6 mm). Repeated measures analysis of variance revealed the CHI to be significantly narrower in symptomatic shoulders than in asymptomatic volunteers (P < .0001).

CONCLUSIONS

These data suggest a role for sonography in diagnosing coracoid impingement.

US guided injections in arthritis

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