Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial

Increasing Efficiency With Point-of-Care Ultrasound-Guided Arthrocentesis: A Case Report and Procedure Demonstration

Patients with chief complaints of musculoskeletal pain comprise a significant portion of emergency department (ED) visits. Identifying and utilizing methods to expedite diagnosis in these cases may help reduce ED crowding, improve outcomes, and increase patient satisfaction. We present a case in which a 52-year-old man presented to the ED with complaints of unilateral right knee pain, swelling, and stiffness. An initial plain film X-ray showed a large suprapatellar effusion over the patient's arthritic right knee. Point-of-care ultrasound (POCUS) was used by an ED physician to facilitate a suprapatellar arthrocentesis. The patient tolerated the procedure well, remarking that he had no pain during or after its completion. POCUS can increase the accuracy, efficacy, and speed of procedures for which physicians have traditionally used landmarks or formal radiology consultations. While POCUS can prove helpful, barriers to its widespread implementation still remain. However, these barriers can be addressed with relative ease.

2023 EULAR recommendations on imaging in diagnosis and management of crystal-induced arthropathies in clinical practice

OBJECTIVE

To formulate evidence-based recommendations and overarching principles on the use of imaging in the clinical management of crystal-induced arthropathies (CiAs).

METHODS

An international task force of 25 rheumatologists, radiologists, methodologists, healthcare professionals and patient research partners from 11 countries was formed according to the EULAR standard operating procedures. Fourteen key questions on the role of imaging in the most common forms of CiA were generated. The CiA assessed included gout, calcium pyrophosphate deposition disease and basic calcium phosphate deposition disease. Imaging modalities included conventional radiography, ultrasound, CT and MRI. Experts applied research evidence obtained from four systematic literature reviews using MEDLINE, EMBASE and CENTRAL. Task force members provided level of agreement (LoA) anonymously by using a Numerical Rating Scale from 0 to 10.

RESULTS

Five overarching principles and 10 recommendations were developed encompassing the role of imaging in various aspects of patient management: making a diagnosis of CiA, monitoring inflammation and damage, predicting outcome, response to treatment, guided interventions and patient education. Overall, the LoA for the recommendations was high (8.46-9.92).

CONCLUSIONS

These are the first recommendations that encompass the major forms of CiA and guide the use of common imaging modalities in this disease group in clinical practice.

Point-of-Care Ultrasound-Guided Arthrocentesis of a Pediatric Septic Ankle

ABSTRACT

Septic arthritis is one potential cause of pediatric joint effusion and pain that may lead to significant morbidity. We present a case where point-of-care ultrasound was used to identify and aspirate a joint effusion in a pediatric patient with septic arthritis of the ankle, facilitating timely diagnosis and care. We review the technique for arthrocentesis of the ankle and literature on point-of-care ultrasound in the diagnosis of pediatric septic arthritis.

Ultrasonography and procedures in intensive care medicine

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.

Measuring success: A comparison of ultrasound and landmark guidance for knee arthrocentesis in a cadaver model

OBJECTIVE

Knee arthrocentesis can be performed by landmark (LM) or ultrasound (US) guidance. The goal of performing knee arthrocentesis is to obtain synovial fluid, however, it is also important to consider the number of attempts required and accidental bone contacts that occur. This study evaluates procedural success without bone contact in knee arthrocentesis and compares both LM and US guided techniques in a cadaver model.

METHODS

This was a randomized crossover study comparing US vs LM guidance for arthrocentesis in a single academic center. Volunteers were randomized to perform both LM and US guided knee arthrocentesis on cadavers. The primary outcome was procedural success, defined as first attempt aspiration of synovial fluid without bone contact. Secondary outcomes included number of attempts, number of bone contacts, time to aspiration, and confidence.

RESULTS

Sixty-one participants completed the study with a total of 122 procedures performed. Procedural success without bone contact was greater in the US group (84% vs 64% p = 0.02). Time to aspiration was longer for US (38.75 s vs 25.54 s p = 0.004). Participants were more confident with US compared to LM both before the procedure on a Visual Analog Scale from 1 to 100 (29 vs 21 p = 0.03) as well as after the procedure (83 vs 69 p = 0.0001). Participants had a greater median increase in confidence with US following training (44 vs 26 p = 0.01).

CONCLUSIONS

Study participants had greater procedural success without bone contact when US guidance was used. The increase in confidence following training was greater for US guidance than the LM method. Use of US guidance may offer a benefit by allowing for better needle control and avoidance of sensitive structures for clinicians performing knee arthrocentesis.

Ultrasound-guided joint interventions of the lower extremity

The purpose of this article is to better understand the role ultrasound plays in lower extremity joint interventions. Ultrasound is an important and reliable tool diagnostically and therapeutically. Real-time feedback, lack of ionizing radiation, and dynamic maneuverability make ultrasound an important tool in the proceduralist's armament. This article will touch upon the important anatomic considerations, clinical indications, and technical step-by-step details for lower extremity ultrasound interventions. Specifically, we will look at interventions involving the hip, knee, ankle, and foot. In addition, this article will discuss the roles corticosteroid and platelet-rich plasma may play in certain interventions.

[Sterile puncture of large joints]

OBJECTIVE

Puncture of large joints is performed for diagnostic purposes on the one hand and for the treatment of joint pathologies on the other. Puncture can be used for rapid pain relief by relieving effusions or intra-articular hematomas. The obtained puncture specimen allows immediate visual assessment and subsequent microscopic-cytological and microbiological evaluation in the laboratory.

INDICATIONS

The indication for puncture of a large joint is for diagnosis and/or therapy of inflammatory, traumatic or postoperative joint problems. Diagnostic punctures are used to obtain punctate, to differentiate the location of pain or (rarely) to apply contrast medium for magnetic resonance arthrography. Therapeutic punctures allow the injection of drugs or platelet-rich plasma (PRP) as well as the relief or drainage of effusions.

CONTRAINDICATIONS

If there are inflammatory skin alterations-especially purulent inflammation-joint punctures through these lesions are absolutely contraindicated. Special attention is necessary if the patients are on anticoagulants.

SURGICAL TECHNIQUE

Absolute sterile handling is mandatory. Unnecessary pain can be avoided by a sterile skin wheal of local anesthesia, safe puncture points, and careful handling of the cannulas.

POSTOPERATIVE MANAGEMENT

Joint aspiration material has to be handled according to the local, intrahospital rules in a timely manner. Puncture sites are covered with sterile dressings, and if intra-articular medication is administered, the joints have to be passively moved through the range of motion to distribute the medication. Thereafter, compression therapy from distally to proximally while also covering the puncture site avoids recurrence of swelling or hematoma.

FACTS

If sterile conditions are guaranteed, infections rarely occur (0.04-0.08%, 4-8/10,000 cases). The risk of false-positive detection of microorganisms is extremely low.