Sonographically guided distal biceps tendon injections: techniques and validation

Distale Bizepssehnenruptur

Die Ruptur der distalen Bizepssehne tritt am häufigsten bei Männern im mittleren Alter auf (30 bis 50 Jahre). Der typische Mechanismus ist die exzentrische Belastung in strecknaher Ellbogenstellung in Supination, wobei diese Verletzung mit Kraftsport und körperlich belastender Tätigkeit assoziiert ist. Epidemiologische Daten weisen auf eine Zunahme von distalen Bizepsrupturen in den letzten Jahrzehnten hin. Risikofaktoren wie die Verwendung anaboler Steroide, Kraftsport und Nikotinabusus zeigen einen Zusammenhang mit der Verletzung. Bei reduziertem Patientenanspruch oder relevanten Komorbiditäten ist auch unter einer konservativen Behandlung ein gutes funktionelles Ergebnis mit subjektiv guter Patientenzufriedenheit zu erreichen, allerdings unter zu erwartender relevanter Kraftminderung in Flexion (20 %) und Supination (40 %). Durch eine operative Refixation lässt sich das beste funktionelle Resultat erzielen, allerdings einhergehend mit einem nicht unerheblichen Komplikationsrisiko.

Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approach at the Distal Biceps Tendon: A Potential Treatment for Biceps Tendinopathy

Distal biceps brachii tendinopathy is a musculoskeletal pain condition-comprising chronic intrasubstance degeneration with alterations of the tendon structure-that is difficult to treat. Preliminary evidence suggests a positive effect for pain and related disability of percutaneous electrolysis treatment in patients with tendinopathy. Ultrasound is an excellent diagnostic tool to identify tendon injuries, such as tendinopathy, and to guide treatment approaches. Different approaches using ultrasound evaluation of the biceps tendon have been described. Our aim was to determine the validity and safety of a percutaneous electrolysis approach, targeting insertion of the distal tendon of biceps brachii, in both human (ultrasound-guided) and Thiel-embalmed cadaver (not ultrasound-guided) models. There were two approaches evaluated: an anterior approach with the elbow in extension and the forearm in supination and a posterior approach with the elbow in flexion and the forearm in pronation. A needle was inserted following the tendon up to its insertion into the radial tuberosity. The anterior approach, both in cadaveric study and US-guided intervention, revealed a close relationship between the distal biceps tendon and the brachial artery. The mean distance of the depth of the biceps tendon distal to the brachial artery was 0.21 ± 0.021 cm in the cadavers and 0.51 ± 0.024 cm in subjects. It was also found that the anterior approach has a potential technical difficulty due to the anatomical location of the brachial artery. With the posterior approach, it was possible to safely identify the tendon insertion and the needle approach, since no important vascular and nervous structures were visualized in the window of insertion of the needle. The clinician rated the posterior approach as low difficulty in all subjects. Current results would support a posterior approach with US guidance as a safe approach for applying the percutaneous electrolysis technique for insertional tendinopathies of the distal biceps brachii tendon. The current study did not assess the effectiveness of the proposed intervention; accordingly, future studies investigating the clinical effectiveness of the proposed intervention are needed.

Distal biceps tendon injection

Background

Injection therapy around the distal biceps tendon insertion is challenging. This therapy may be indicated in patients with a partial distal biceps tendon tear, bicipitoradial bursitis and tendinopathy. The primary goal of this study was to determine the accuracy of manually performed injections without ultrasound guidance around the biceps tendon.

Methods

Seven upper limb specialists, two general orthopedic specialists, and three orthopedic surgical residents manually injected a cadaver elbow with acrylic dye using an anterior and a lateral infiltration approach. After infiltration the cadaveric elbows were dissected to determine the location of the acrylic dye.

Results

In total, 79% of the injections were localized near the biceps tendon. Of these injections, 20% were localized on the radius near the bicipitoradial bursa. In total, 53% of the performed infiltrations were injected by anterior and 47% by lateral approaches. Of the injections near the distal biceps (79%), 47% were injected by an anterior and 53% by a lateral approach. Of the injections on the radius (20%), 33% were injected by anterior and 67% by lateral approach. Of the inaccurate injections (21%), 75% were injected anterior and 25% lateral.

Conclusions

Manual infiltration without ultrasound guidance for distal biceps pathology lacks accuracy. We therefore recommend ultrasound guidance for more accurate infiltration.

Ultrasound of the distal biceps brachii tendon using four approaches: reproducibility and reader preference

OBJECTIVES

To determine which sonographic appearance of the distal biceps brachii tendon (DBBT) is preferred by readers, and if images obtained by two different operators are reproducible.

METHODS

We performed an IRB-approved prospective sonographic evaluation of the DBBT in 50 healthy elbows using four different approaches (anterior, lateral, medial, posterior) performed by two operators. Five musculoskeletal radiologists independently reviewed the images, and ranked the four approaches based on overall appearance of echogenicity of the tendon, visualized length, and visualization of the insertion.

RESULTS

The medial approach was preferred in 79.6% of elbows, anterior in 17.6%, lateral in 2.8%, and the posterior approach was never preferred. The difference was statistically significant (P < 0.001). Kappa values for the five readers were 0.61 to 0.8 for choosing the images produced by the medial approach.

CONCLUSION

The appearance of the DBBT using the medial approach is preferred by readers and is reproducible between different operators.

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 II, elbow and wrist

BACKGROUND

Although image-guided interventional procedures of the elbow and wrist are routinely performed, there is poor evidence in the literature concerning such treatments. Our aim was to perform a Delphi-based consensus on published evidence on image-guided interventional procedures around the elbow and wrist and provide clinical indications on this topic.

METHODS

A board of 45 experts in image-guided interventional musculoskeletal procedures from the European Society of Musculoskeletal Radiology were involved in this Delphi-based consensus study. All panelists reviewed and scored published papers on image-guided interventional procedures around the elbow and wrist updated to September 2018 according to the Oxford Centre for Evidence-based Medicine levels of evidence. Consensus on statements drafted by the panelists about clinical indications was considered as "strong" when more than 95% of panelists agreed and as "broad" if more than 80% agreed.

RESULTS

Eighteen statements were drafted, 12 about tendon procedures and 6 about intra-articular procedures. Only statement #15 reached the highest level of evidence (ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement). Seventeen statements received strong consensus (94%), while one received broad consensus (6%).

CONCLUSIONS

There is still poor evidence in published papers on image-guided interventional procedures around the elbow and wrist. A strong consensus has been achieved in 17/18 (94%) statements provided by the panel on clinical indications. Large prospective randomized trials are needed to better define the role of these procedures in clinical practice.

KEY POINTS

• The panel provided 18 evidence-based statements on clinical indications of image-guided interventional procedures around the elbow and wrist. • Only statement #15 reached the highest level of evidence: ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement. • Seventeen statements received strong consensus (94%), while broad consensus was obtained by 1 statement (6%).

Ultrasound-Guided Elbow Procedures

High-resolution ultrasonography can help clinicians visualize key anatomic structures of the elbow and guide periarticular and intra-articular injections. Historically, most procedures done around the elbow have been done using landmark guidance, and few studies have reported the accuracy of ultrasonography-guided injections in the elbow region. This article reviews common musculoskeletal disorders about the elbow that can be evaluated with ultrasonography, reviews the literature on ultrasonography-guided injections of the elbow region, and describes the senior author's preferred approach for the most commonly performed elbow region injections.

Ultrasound-Guided Distal Bicep Tendon Injection Using a Posterior Approach

Distal biceps tendinopathy is an uncommon but increasingly diagnosed condition in persons with elbow pain. When traditional treatments are unsuccessful, practitioners have performed ultrasound (US)-guided tendon injections in this region using an anterior approach. Although success has been reported with this technique, this approach may lead to neurovascular injury. This case report is the first in the literature to describe a US-guided distal bicep tendon injection using a posterior approach. The patient had an excellent clinical outcome with no adverse events. This outcome suggests that a US-guided posterior percutaneous tendon injection might be a safe, viable, nonsurgical option for recalcitrant distal biceps tendinopathy.