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

Current evidence and practical knowledge for ultrasound-guided procedures in rheumatology: Joint aspiration, injection, and other applications

Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.

A novel infrapatellar approach of ultrasound-guided intra-articular injection of the knee from both lateral and medial side: a case series

Knee osteoarthritis (OA) is common. Ultrasound-guided intra-articular injection (UGIAI) using the superolateral approach is currently the gold standard for treating knee OA, but it is not 100% accurate, especially in patients with no knee effusion. Herein, we present a case series of chronic knee OA treated with a novel infrapatellar approach to UGIAI. Five patients with chronic grade 2-3 knee OA, who had failed on conservative treatments and had no effusion but presented with osteochondral lesions over the femoral condyle, were treated with UGIAI with different injectates using the novel infrapatellar approach. The first patient was initially treated using the traditional superolateral approach, but the injectate was not delivered intra-articularly and became trapped in the pre-femoral fat pad. The trapped injectate was aspirated in the same session due to interference with knee extension, and the injection was repeated using the novel infrapatellar approach. All patients who received the UGIAI using the infrapatellar approach had the injectates successfully delivered intra-articularly, as confirmed with dynamic ultrasound scanning. Their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, stiffness, and function scores significantly improved 1 and 4 weeks post-injection. UGIAI of the knee using a novel infrapatellar approach is readily learned and may improve accuracy of UGIAI, even for patients with no effusion.

Ultrasound in primary care: Consensus recommendations on its applications and training. Results of a 3-round Delphi study

BACKGROUND

The introduction of portable and pocket ultrasound scanners has potentiated the use of ultrasound in primary care, whose many applications have been studied, analyzed and collected in the literature. However, its use is heterogeneous in Europe and there is a lack of guidelines on the necessary training and skills.

OBJECTIVES

To identify the fundamental applications and indications of ultrasound for family physicians, the necessary knowledge and skills, and the definition of a framework of academic and pragmatic training for the development of these competencies.

METHODS

A modified 3-round Delphi study was carried out in Catalonia, with the participation of 65 family physicians experts in ultrasound. The study was carried out over six months (from September 2020 to February 2021). The indications of ultrasound for family physicians were agreed (the > = 75th percentile was considered) and prioritised, as was the necessary training plan.

RESULTS

The ultrasound applications in primary care were classified into seven main categories. For each application, the main indications (according to reason for consultation) in primary care were specified. A progressive training plan was developed, characterised by five levels of competence: A (principles of ultrasound and management of ultrasound scanners); B (basic normal ultrasound anatomy); C (advanced normal ultrasound anatomy); D (pathologic ultrasound, description of pathological images and diagnostic orientation); E (practical skills under conditions of routine clinical practice).

CONCLUSION

Training family physicians in ultrasound may consider seven main applications and indications. The proposed training plan establishes five different levels of competencies until skill in real clinical practice is achieved.

Ultrasound-guided injection with hyaluronic acid in hip osteoarthritis: efficacy and safety in a real-life setting

BACKGROUND

For knee OA, EULAR has included hyaluronic acid (HA) intra-articular injection in the 2003 recommendations, making the intra-articular injection a sound therapeutic option. The ultrasound-guided intra-articular injections (USGIAI) have been demonstrated to be more efficient and safe in comparison to the blind procedure. Our objectives were to evaluate the short- and medium-term efficacy and safety of USGIAI of HA in moderate hip OA and patients' additional NSAIDs/pain killer intake.

PATIENTS AND METHODS

Patients with hip OA (KLG II/III), that failed standard of care therapy, received 3 consecutive HA-USGIAI (case group) while other patients (KLG II/III) treated according to current guidelines were chosen as a control group. Demographic data, comorbidities and medication intake were recorded. VAS pain scale and WOMAC score were performed at baseline and at 3 months. In the case group, they were additionally scored at 6 months. At baseline and at 6 months, hip X-ray assessment was also made. Ultrasound evaluation was made at each visit.

RESULTS

In the case group, 15 patients were enrolled and 28 hip joints were injected. The control group consisted of 17 hip OA patients. In the case group, pain evaluated by VAS score and WOMAC score were significantly and progressively decreased (p < 0.0001) from baseline up to 3 and 6 months, respectively. Indeed, the case group showed a significantly lower NSAIDs/pain killer median intake at 3 months from baseline (p < 0.05).

CONCLUSION

Our data suggest that HA-USGIAI may be an effective and safe treatment for moderate hip OA with short- and medium-term benefits. Key Points • US hip evaluation before interventional maneuvers may identify capsular distension suggestive for concomitant septic involvement, microcrystal arthropathy or incipient hip osteonecrosis. • USGIAI may be fundamental to achieve an efficacious and safe injection. • HA-USGIAI may be an effective and safe treatment for moderate hip OA with short- and medium-term benefits.

A vibration sensor approach to detect intra-articular needle tip placement in the knee joint: a proof-of-concept study

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.

Real-world Outcomes of Ultrasonography-guided Interventions in a Tertiary Hospital

BACKGROUND

Intervention under ultrasonography (US) guidance has become increasingly prevalent in recent years. This study aimed to assess the treatment response to US-guided musculoskeletal interventions in daily practice.

METHODS

This retrospective study sought to identify the treatment response to US-guided interventions in different tissues conducted between January 2017 and December 2018. The treatment response to various US-guided interventions in different tissues was recorded. The response was further classified into positive response and negative response according to the improvement of symptoms or satisfaction of the treatment.

RESULTS

Among the 605 interventions included for data analysis, a positive response rate of 81% was observed in this study for all US-guided interventions, ranging from 70% to 88% in different categories.

CONCLUSION

This real-world analysis demonstrated the effectiveness of various US-guided interventions without serious complications. We recommend US as a useful guidance for a variety of injections.

Ultrasound indications for chronic pain management: an update on the most recent evidence

PURPOSE OF REVIEW

The ability of ultrasound to provide detailed anatomic visualization while avoiding radiation exposure continues to make it an appealing tool for many practitioners of chronic pain management. This review will present the most recent evidence regarding the use of ultrasound-guidance for the performance of interventional procedures in the treatment of chronic pain.

RECENT FINDINGS

For a variety of different procedures, studies continue to compare ultrasound-guided techniques to commonly used fluoroscopic or landmark-based techniques. Small, randomized controlled trials are beginning to demonstrate that ultrasound-guided approaches to interventional pain procedures can be as well tolerated and effective as the traditionally used techniques, while providing some potential advantages in terms of decreased radiation exposure, avoidance of vascular structures, and in some cases, improved efficiency and decreased rates of adverse effects.

SUMMARY

Despite continued interest in ultrasound-guided techniques for chronic pain management procedures, the evidence is still limited mainly to small, randomized trials and case series. For some procedures, such as stellate ganglion block and peripheral joint injections, recent evidence appears to be tilting in favor of ultrasound-guidance as the preferred technique, though fluoroscopy continues to be a much more reliable method for detection of intravascular uptake of injectate.

Ultrasound-guided interventional procedures for chronic pain management

Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. It has proved superiority at accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. Although limited in its ability to see through bony structures, ultrasound has utility in visualizing soft tissues and vascular structures in anatomic regions of interest resulting in increased use for posterior neuraxial, periaxial, peripheral nerve and joint-related structures. Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities.