Aspiration and Injection Techniques of the Lower Extremity

The preferred technique for knee synovium biopsy and synovial fluid arthrocentesis

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.

Safe and Effective Aspirations and Nerve Blocks for the On-Call Orthopaedic Surgeon

The on-call orthopaedic surgeon is faced with a wide array of orthopaedic pathology for which intra-articular aspiration, injection, and/or nerve/hematoma block may be used. Efficient use of these diagnostic and therapeutic modalities affords better patient care and a more effective on-call period. Often, these interventions are the rate limiting factor in a reduction or diagnosis. In this review, we describe joint aspirations, saline load tests, hematoma blocks, and nerve blocks in detail to include their indications, techniques, related pharmacology, pearls, and pitfalls.

Is ultrasound-guided hip aspiration more successful than fluoroscopic-guided aspiration in diagnosing prosthetic joint infection?

Introduction: aspiration of total hip arthroplasty (THA) is commonly performed to assist in the diagnosis of prosthetic joint infection (PJI). This study aimed to determine whether fluoroscopic- or ultrasound- guided hip aspiration differs in the ability to acquire synovial fluid and in the accuracy of diagnosing infection. Methods: all THA aspirations performed between 2014 and 2021 at our institution were retrospectively identified. Aspirations were classified as successful or dry. If successful, the volume of fluid obtained was recorded. The sensitivity and specificity of hip aspiration in identifying PJI were calculated with four methods: (1) culture results excluding saline lavage, (2) culture results including saline lavage, (3) 2018 Musculoskeletal Infection Society (MSIS) International Consensus Meeting (ICM) criteria, and (4) 2021 European Bone and Joint Infection Society (EBJIS) criteria. Analyses were performed using Student's t test or Wilcoxon rank sum for continuous variables and chi-squared or Fisher's exact test for categorical variables. Results: 290 aspirations were included (155 fluoroscopic-guided and 135 ultrasound-guided). Success of aspiration (> 0.5  mL) was more common in the ultrasound cohort (69 %) than fluoroscopy (53 %) (p < 0.0055 ). When successful, more volume was obtained in the ultrasound cohort (mean 13.1 mL vs. 10.0 mL; p = 0.0002 ). Ultrasound-guided aspiration was more sensitive than fluoroscopy in diagnosing PJI using culture results excluding saline lavage (85 % vs. 73 %; p = 0.03 ), culture results including saline lavage (85 % vs. 69 %; p = 0.001 ), 2018 MSIS-ICM criteria (77 % vs. 52 %; p = 0.02 ), and 2021 EBJIS criteria (87 % vs. 65 %; p = 0.02 ). Ultrasound-guided aspiration was more specific than fluoroscopy in diagnosing PJI using 2021 EBJIS criteria (100 % vs. 96 %; p = 0.001 ). Conclusions: ultrasound-guided aspiration is more frequently successful and yields more fluid than fluoroscopic-guided aspiration of THA. Ultrasound-guided aspiration is more sensitive in diagnosing PJI than fluoroscopy using culture data, 2018 MSIS-ICM criteria, and 2021 EBJIS criteria.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.

Unravelling the mysteries of gout by multimodality imaging

Gout is a common inflammatory arthritis that manifests as an aggregate of variably symptomatic monosodium urate crystals (MSU) in the joints and surrounding tissues in addition to multisystem involvement such as genitourinary and cardiovascular systems. In recent decades, there has been a documented increase in the prevalence and incidence of gout. Risk factors for gout include obesity, dietary influences, hypertension, renal impairment, and diuretic use. A prompt diagnosis followed by uric acid lowering treatment prior to the onset of bone destruction is the goal in any suspected case of gout. Advanced imaging modalities, such as dual energy computed tomography (DECT) and ultrasonography (US), employed for the diagnosis of gout are each accompanied by advantages and disadvantages. Conventional radiography (CR), although useful in visualizing joint erosions and mineralization, is limited in its ability to diagnose gout flare. Although synovial fluid aspiration remains the gold standard for MSU crystal visualization, less-invasive imaging modalities are preferred to avoid potential complications. DECT and US in particular are useful in the diagnosis of gout. In this review, we will discuss the current state and role of imaging in the detection of gout.

Treatment of Achilles Tendinopathy in Recreational Runners with Peritendinous Hyaluronic Acid Injections: A Viscoelastometric, Functional, and Biochemical Pilot Study

BACKGROUND

Achilles tendinopathy (AT) affects ca. 10 million recreational runners in Europe; the practice of hyaluronic acid (HA) infiltration is being increasingly adopted. The aim of this pilot study was to monitor the effects of a three-local time-spaced injections regimen of HA in the treatment of AT in middle-aged runners combining for the first time viscoelastometric, biochemical, and functional methodologies with routine clinical examinations.

METHODS

Eight male runners (Age 49.3 ± 3.9), diagnosed for unilateral AT, were given three ultrasound (US) guided peritendinous HA injections at the baseline (T0) and every fifteenth day with a follow-up on the forty-fifth day (T1, T2, and T3). At all-time points patients were assessed for viscoelastic tone and stiffness, maximal voluntary isometric contraction (MVIC), and pain level (Likert scale 0-5). The peritendinous effusions of the injured tendon were collected at T0 and T2 to quantify the volume variations and the IL-1β and MMP-3 levels.

RESULTS

At T0 MVIC and pain score were significantly lower and higher, respectively, in injured tendons. The volume, IL-1β and MMP-3 levels decreased in the course of treatment and the clinical endpoints ameliorated over time. Tone, stiffness, and functional performance also varied significantly at T2 and T3, as compared to T0.

CONCLUSIONS

The sequential peritendinous injections of HA were effective in the amelioration of the clinical symptoms, as well as of the functional and viscoelastic state associated with AT. The determination of the viscoelastometric state may help to precisely evaluate the healing process in AT patients.

Anatomic Landmark-Guided Hip Aspiration in the Diagnosis of Periprosthetic Joint Infection

Hip aspirations used to detect a periprosthetic joint infection (PJI) are usually performed under fluoroscopy or ultrasound. The aim of this study was to evaluate the results of simply using anatomic landmarks for aspiration and detecting PJI without the use of any complicated technologies. The authors retrospectively reviewed a total of 186 consecutive hip aspirations performed between April 2015 and December 2018. All patients were suspected to have infections after total hip arthroplasty. The procedures were performed with the patients in the supine position. The authors aimed to aspirate at the neck of the prosthesis. They located the y-axis of the puncture point approximately 2 to 3 cm lateral to the pulse of the femoral artery in the region of the inguinal ligament. The x-axis was estimated by using the pubic symphysis or greater trochanter according to an anteroposterior radiograph of the hip joint. The aspiration failure rate, incidence of complications, and culture results were recorded. The overall aspiration failure rate was 3.8% (7 of 186). No obvious complications related to aspiration were observed. The saline lavage and reaspiration rate was 45.3% (81 of 179) due to "dry taps." The sensitivity, specificity, positive predictive value, and negative predictive value of the remaining 169 patients with definite diagnoses were 0.781 (95% CI, 0.678-0.860), 0.939 (95% CI, 0.857-0.977), 0.931 (95% CI, 0.841-0.975), and 0.802 (95% CI, 0.706-0.874), respectively. Anatomic landmark-guided hip aspiration was a convenient method that could provide satisfactory detection of PJI. [Orthopedics. 2021;44(1):e85-e90.].

Superior gluteal nerve injury following landmark-guided corticosteroid injection for greater trochanteric pain: A case report

This report describes an isolated superior gluteal nerve injection injury following a corticosteroid injection for greater trochanteric pain syndrome. Ultrasound-guided injections may be beneficial to target multiple pain-producing regions of the hip while avoiding nerves and tendons.

Ultrasound-Guided Biopsies: Medium and Large Joints

Ultrasound-guided needle synovial biopsies are useful for clinical practice and research in rheumatology. With the emergence of personalized medicine for the treatment of inflammatory rheumatic diseases, it is predicted that this technique will be increasingly used in the near future. Standardized characterization of the technical aspects of ultrasound-guided needle synovial biopsies is needed in order to produce solid evidence on the safety and effectiveness of the technique.