Importance of placement of intra-articular steroid injections

The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathology--a systematic review and meta-analysis

OBJECTIVE

To compare the clinical and functional outcomes of US-guided (USG) vs landmark-guided (LMG) injection for the treatment of adults with shoulder pathology.

METHOD

MEDLINE, AMED and Embase in addition to unpublished literature databases were searched from 1950 to August 2011. Studies were included if they were randomized or non-randomized controlled trials comparing USG vs LSG injections for the treatment of adults with shoulder pathology. Two reviewers independently performed data extraction and appraisal of the studies. Meta-analyses were performed where possible and when inappropriate a narrative review of the data was presented.

RESULTS

Six papers including 307 patients were reviewed; 142 received LMG injections and 165 received USG injections. There was a statistically significant difference in favour of USG for pain at 6 weeks (standardized mean difference 1.03; 95% CI 0.12, 1.93; P = 0.03). There was no statistically significant difference between the injection methods with respect to shoulder function (standardized mean difference 0.33; 95% CI -0.59, 1.25; P = 0.48). There was a significant difference between interventions for shoulder abduction at 6 weeks in favour of the USG method (mean difference 2.81; 95% CI 0.67, 4.95; P = 0.01). No other movements showed a statistically significant difference.

CONCLUSION

There is a statistically significant difference in pain and abduction between LMG and USG steroid injections for adults with shoulder pathology. However, these differences are small and may not represent clinically useful differences. The current evidence base is limited by a number of important methodological weaknesses, which should be considered when interpreting these findings. The cost-effectiveness of the intervention should be considered in the design of future studies.

Ultrasound-guided corticosteroid injection therapy for juvenile idiopathic arthritis: 12-year care experience

BACKGROUND

Intra-articular corticosteroid injections are a safe and effective treatment for patients with juvenile idiopathic arthritis. The potential scope of care in ultrasound-guided corticosteroid therapy in children and a joint-based corticosteroid dose protocol designed to optimize interdisciplinary care are not found in the current literature.

OBJECTIVE

The purpose of this study was to report the spectrum of care, technique and safety of ultrasound-guided corticosteroid injection therapy in patients with juvenile idiopathic arthritis and to propose an age-weight-joint-based corticosteroid dose protocol.

MATERIALS AND METHODS

A retrospective analysis was performed of 198 patients (ages 21 months to 28 years) referred for treatment of juvenile idiopathic arthritis with corticosteroid therapy. Symptomatic joints and tendon sheaths were treated as prescribed by the referring rheumatologist. An age-weight-joint-based dose protocol was developed and utilized for corticosteroid dose prescription.

RESULTS

A total of 1,444 corticosteroid injections (1,340 joints, 104 tendon sheaths) were performed under US guidance. Injection sites included small, medium and large appendicular skeletal joints (upper extremity 497, lower extremity 837) and six temporomandibular joints. For patients with recurrent symptoms, 414 repeat injections were performed, with an average time interval of 17.7 months (range, 0.5-101.5 months) between injections. Complications occurred in 2.6% of injections and included subcutaneous tissue atrophy, skin hypopigmentation, erythema and pruritis.

CONCLUSION

US-guided corticosteroid injection therapy provides dynamic, precise and safe treatment of a broad spectrum of joints and tendon sheaths throughout the entire pediatric musculoskeletal system. An age-weight-joint-based corticosteroid dose protocol is effective and integral to interdisciplinary care of patients with juvenile idiopathic arthritis.

The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers

BACKGROUND

Injections of the acromioclavicular joint (ACJ) are performed routinely in patients with ACJ arthritis, both diagnostically and therapeutically. The aim of this prospective controlled study was to estimate the frequency of successful intra-articular ACJ injections with the aid of sonographic guidance versus non-guided ACJ injections.

MATERIALS AND METHODS

A total of 80 cadaveric ACJs were injected with a solution containing methylene blue and subsequently dissected to distinguish intra- from peri-articular injections. In 40 cases the joint was punctured with sonographic guidance, whereas 40 joints were injected in the control group without the aid of ultrasound.

RESULTS

The rate of successful intra-articular ACJ injection was 90% (36 of 40) in the guided group and 70% (28 of 40) in the non-guided group. Ultrasound was significantly more accurate for correct intra-articular needle placement (P = .025).

DISCUSSION

The use of ultrasound significantly improves the accuracy of ACJ injection.

Injectable medications for osteoarthritis

Osteoarthritis is one of the most frequent and chronic conditions that affect the U.S. population. Use of intra-articular injections is one of the established treatment options available in the nonoperative care for the management of symptomatic osteoarthritis. Common injectable medications include corticosteroids, hyaluronic acid, and other less traditional compounds (for example, botulinum toxin). Corticosteroids work by anti-inflammatory and antinociceptive actions. Corticosteroids have been shown to decrease pain and symptoms associated with osteoarthritis for up to 3 weeks. Hyaluronic acid has an unclear mechanism of action, but it is thought to promote the restoration of hyaluronic acid within an osteoarthritic joint. The efficacy of hyaluronic acid is modest and is most beneficial between 5 and 13 weeks after treatment. Other injectable compounds have been studied and include botulinum toxin type A, which has been theorized to work as an antinociceptive agent. One must be aware of the potential adverse effects associated with these medications. For all of these injectable treatments, the placebo effect must not be overlooked, because it has be demonstrated in multiple studies that these medications provide similar relief of pain when compared with placebo. Image guidance with ultrasound or fluoroscopy may be considered when performing intra-articular injections to improve accurate placement of medication.

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.

Clinical utility of ultrasound guidance for intra-articular knee injections: a review

Intra-articular corticosteroid and hyaluronic acid injections provide short-term symptom amelioration for arthritic conditions involving structural damage or degenerative changes in the knee. Conventional palpation-guided anatomical injections frequently result in inaccurate needle placement into extra-articular tissue and adjacent structures. The purpose of this review was to determine the effect of ultrasound guidance on the accuracy of needle placement, clinical outcomes, and cost-effectiveness in comparison with anatomical landmark-guided intra-articular large joint injections, with particular emphasis on the knee. A total of 13 relevant studies were identified; five studied the knee, seven studied the shoulder, one used both the knee and shoulder, and none studied the hip. Ultrasound was used in seven studies; the remaining studies utilized air arthrography, fluoroscopy, magnetic resonance arthrography, or magnetic resonance imaging. Across all studies (using all imaging modalities and all joints), needle placement accuracy ranged from 63% to 100% with ultrasound and from 39% to 100% with conventional anatomical guidance. Imaging guidance improved the accuracy of intra-articular injections of the knee (96.7% versus 81.0%, P < 0.001) and shoulder (97.3% versus 65.4%, P < 0.001). In particular, ultrasound guidance of knee injections resulted in better accuracy than anatomical guidance (95.8% versus 77.8%, P < 0.001), yielding an odds ratio of 6.4 (95% confidence interval 2.9-14). Ultrasound guidance notably improves injection accuracy in the target intra-articular joint space of large joints including the knee. The enhanced injection accuracy achieved with ultrasound needle guidance directly improves patient-reported clinical outcomes and cost-effectiveness.

Accuracy of intra-articular injections of the glenohumeral joint through an anterior approach: arthroscopic correlation

BACKGROUND

Intra-articular injections of the glenohumeral joint are an important tool for orthopedic surgeons who treat the spectrum of shoulder disorders. Previous studies, however, have suggested that these injections may not be reliably placed intra-articularly in the glenohumeral joint when performed in the office setting and that radiographic assistance may be necessary. This study assessed the accuracy of a glenohumeral injection through an anterior approach with arthroscopic confirmation.

MATERIALS AND METHODS

The study included 75 consecutive patients who were undergoing routine shoulder arthroscopy for a variety of shoulder disorders. All underwent anterior placement of a 1.5-inch, 21-gauge needle using a location just lateral to the coracoid and angled 45° toward the glenohumeral joint. After injection of sterile saline, a diagnostic arthroscopy was initiated through a standard posterior portal. The needle was considered intra-articular if fluid was expressed from the eyelet of the needle when the arthroscopy pump was turned on or with direct visualization of the needle with the arthroscope, or both.

RESULTS

The needle was visualized with the arthroscope in all 75 patients (100%). In 70 patients (93.3%), fluid was expressed through the eyelet of the needle when the arthroscopy pump was turned on.

CONCLUSIONS

The results of this study show that an anterior injection into the glenohumeral joint can be accurately placed without radiographic assistance using standard landmarks. The technique used is similar to making a standard rotator interval portal during shoulder arthroscopy; therefore, it is most successful in the hands of experienced shoulder arthroscopists.

[Ultrasound-guided joint injections in patients with rheumatic diseases]

Joint and soft tissue injections are routinely performed in daily rheumatology practice to establish the diagnosis or as part of the treatment in patients suffering from rheumatic diseases. Consequently, joint injections have been included in the rheumatology further training curriculum. Despite numerous studies demonstrating a poor accuracy and outcome of joint injections guided only by clinical examination, most of the injection procedures are still performed in a "blind" fashion based on clinical judgment. Ultrasound has evolved as an established imaging method in rheumatology within the past decade and is considered the preferred imaging modality for joint interventions due to its availability and lack of radiation exposure. In this article the indications and important aspects of the practical management of ultrasound-guided injections performed in daily rheumatology practice are summarized.

The most accurate approach for intra-articular needle placement in the knee joint: a systematic review

INTRODUCTION

Intra-articular needle placement in the knee joint, such as injection or aspirations, are commonly used for therapeutic, diagnostic, and research purposes. Although several approaches can be used to establish an intra-articular injection or aspiration of the knee joint, the accuracy differs per approach.

OBJECTIVE

To summarize the evidence concerning the accuracy of different approaches for intra-articular needle placements in the knee. Additionally, to assess whether the accuracy of different approaches is related to factors such as underlying disease, severity of underlying disease, approach-related factors, and/or the rate of local reactions.

METHODS

The literature was systemically reviewed until July 2010. Risk of bias of the included studies was assessed by the QUADAS tool. Study characteristics were extracted; accuracy results were pooled per approach.

RESULTS

Nine studies were included. The superolateral approach with the leg in extension was studied most (230 injections) and resulted in the highest pooled accuracy of 91% (95% CI 84-99%). The lateral midpatellar approach, the anterolateral approach, and the anteromedial approach resulted in the lowest pooled accuracy rates, 85% (95% CI 68-100%), 67% (95% CI 43-91%) and 72% (95% CI 65-78%), respectively.

CONCLUSIONS

The superolateral approach was investigated most and resulted in the highest pooled accuracy rate of 91% (95% CI 84-99%). Nevertheless, this approach still results in a substantial amount of extra-articular needle placements. Guidance of intra-articular needle placements by imaging techniques may enhance the accuracy. The costs and extra time associated with these techniques should be taken into consideration.

Accuracy of blind versus ultrasound-guided suprapatellar bursal injection

PURPOSE

To compare the accuracy rates between ultrasound (US)-guided and blind knee intra-articular injection via the suprapatellar bursa.

METHODS

Ninety-nine patients with radiographically confirmed knee osteoarthritis (Kellgren/Lawrence grade 2 or 3) without effusion were included. Fifty patients were assigned to the US-guided injection group and 49 to the blind injection group. After a US-guided or blind injection of hyaluronic acid (HA) and contrast dye through the suprapatellar bursa into the knee joint, a radiographic image was obtained in each case to ascertain whether all injected material had reached the intra-articular space.

RESULTS

US-guided HA injection exhibited a significantly greater accuracy (48 of 50 knees, 96.0%) than blind injection (41 of 49 knees, 83.7%).

CONCLUSIONS

Intra-articular injections through the suprapatellar bursa under US guidance increased the accuracy of knee joint injections.

Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?

OBJECTIVE

The present randomized controlled trial compared arthrocentesis of the effusive knee followed by corticosteroid injection performed by the conventional anatomic landmark palpation-guided technique to the same procedure performed with ultrasound (US) needle guidance.

METHODS

Sixty-four palpably effusive knees were randomized to (i) palpation-guided arthrocentesis with a conventional 20-mL syringe (22 knees), (ii) US-guided arthrocentesis with a 25-mL reciprocating procedure device (RPD) mechanical aspirating syringe (22 knees), or (iii) US-guided arthrocentesis with a 60-mL automatic aspirating syringe (20 knees). The one-needle two-syringe technique was used. Outcome measures included patient pain by the Visual Analogue Scale (VAS) for pain (0-10 cm), the proportion of diagnostic samples, synovial fluid volume yield, complications, and therapeutic outcome at 2 weeks.

RESULTS

Sonographic guidance resulted in 48% less procedural pan (VAS; palpation-guided: 5.8 ± 3.0 cm, US-guided: 3.0 ± 2.8 cm, p < 0.001), 183% increased aspirated synovial fluid volumes (palpation-guided: 12 ± 10 mL, US-guided: 34 ± 25 mL, p < 0.0001), and improved outcomes at 2 weeks (VAS; palpation-guided: 2.8 ± 2.4 cm, US-guided: 1.5 ± 1.9 cm, p = 0.034). Outcomes of sonographic guidance with the mechanical syringe and automatic syringe were comparable in all outcome measures.

CONCLUSIONS

US-guided arthrocentesis and injection of the knee are superior to anatomic landmark palpation-guided arthrocentesis, resulting in significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.

Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral approach: a cadaveric study

OBJECTIVES

To evaluate the accuracy of ultrasound (US)-guided and palpation-guided knee injections by an experienced and a less-experienced clinician with use of a superolateral approach.

DESIGN

Single-blinded, prospective study.

SETTING

Academic institution procedural skills laboratory.

PARTICIPANTS

Twenty cadaveric knee specimens without trauma, surgery, or major deformity.

INTERVENTION

US-guided and palpation-guided knee injections of colored liquid latex were performed in each specimen by an experienced and a less-experienced clinician with use of a superolateral approach. The order of injections was randomized. The specimens were subsequently dissected by a blinded investigator and assessed for accuracy.

MAIN OUTCOMES

Accuracy was divided into 3 categories: (1) accurate (all of the injectate was within the joint), (2) partially accurate (some of the injectate was within the joint and some was within the periarticular tissues), and (3) inaccurate (none of the injectate was within the joint). The accuracy rates were calculated for each clinician and guidance method.

RESULTS

US-guided knee injections that used a superolateral approach were 100% accurate for both clinicians. Palpation-guided knee injections that used a superolateral approach were significantly influenced by experience, with the less-experienced investigator demonstrating an accuracy rate of 55% (95% confidence interval = 34%-74%) and the more experienced investigator demonstrating an accuracy rate of 100% (95% confidence interval = 81%-100%).

CONCLUSIONS

US-guided knee injections that use a superolateral approach are very accurate in a cadaveric model, whereas the accuracy of palpation-guided knee injections that use the same approach is variable and appears to be significantly influenced by clinician experience. These findings suggest that US guidance should be considered when one performs knee injections with a superolateral approach that require a high degree of accuracy.

Accuracy of intra-articular injection of the glenohumeral joint: a modified anterior approach

PURPOSE

This study examined the accuracy of our modified anterior approach to the glenohumeral joint using arthrography.

METHODS

Two hundred fifty-six consecutive patients with adhesive capsulitis received the glenohumeral joint injection: a mixture of 1 mL of 40 mg of triamcinolone hexacetonide, 2 mL of 2% lidocaine, 3 mL of contrast medium (Ioxitalamate), and 4 mL of normal saline solution, for a total of 10 mL, through a modified anterior approach. Anteroposterior, lateral, and axial arthrography after each injection was performed to determine the accuracy and patterns of the injection. The injection was judged to be successful if some of the contrast medium was placed within the joint.

RESULTS

There were 78 male and 178 female patients, and the mean age was 54 years (range, 28 to 87 years). In 232 of the 256 patients (90.6%), the injection was deemed to have reached the glenohumeral joint, and these cases were considered successful. Among these patients, the contrast medium was shown only in the joint in 189 (73.8%), whereas in 43 (16.8%) it was shown both in and out of the joint. Of the 24 misguided injections, 15 (5.9%) had anterior placement, 6 (2.3%) had posterior placement, and 2 (0.8%) had superior placement, whereas the material was located in all portions outside the joint in 1 (0.4%).

CONCLUSIONS

This study showed that our modified anterior approach had an accuracy greater than 90% for the intra-articular injection of the glenohumeral joint without radiographic guidance.

The efficacy, accuracy and complications of corticosteroid injections of the knee joint

PURPOSE

Corticosteroid knee injections are being increasingly used in the conservative management of knee osteoarthritis. The procedure is usually performed in secondary care by orthopaedic surgeons and rheumatologists, but as the role of general practitioners in chronic disease management expands, joint injections are now frequently being performed in primary care. It is commonly perceived amongst clinicians that the benefits of corticosteroid knee joint injections in treating symptomatic knee osteoarthritis significantly outweigh the risks of complications.

METHODS

The evidence in the literature for the benefits, accuracy, safety and complications of corticosteroid knee injections in osteoarthritis is reviewed. The perception that serious complications are rare is addressed, and the incidence of infectious complications is estimated.

RESULTS AND CONCLUSIONS

Short-term symptomatic relief is the only evidence-based benefit of corticosteroid injection of an osteoarthritic knee. Accurate intra-articular placement is not achieved in up to 20% of injections and varies considerably with the anatomical approach used. There is no evidence that a medial approach is more accurate. The incidence of serious infectious complications following knee joint injections ranges widely, and may be as high as 1 in 3,000 and potentially far higher in high-risk patients for whom specialist management is advised.

Accuracy of glenohumeral joint injections: comparing approach and experience of provider

BACKGROUND

The purpose of this study was to prospectively evaluate the accuracy of three different approaches used for glenohumeral injections. In addition, the accuracy of the injection was compared to the experience and confidence of the provider.

METHODS

One-hundred six consecutive patients with shoulder pain underwent attempted intra-articular injection either posteriorly, supraclavicularly, or anteriorly. Each approach was performed by an experienced and inexperienced provider. A musculoskeletal radiologist blinded to technique used and provider interpreted fluoroscopic images to determine accuracy. Providers were blinded to these results.

RESULTS

The accuracy of the anterior approach regardless of experience was 64.7%, the posterior approach was 45.7%, and the supraclavicular approach was 45.5%. With each approach, experience did not provide an advantage. For the anterior approach, the experienced provider was 50% accurate compared to 85.7%. For the posterior approach, the experienced provider had a 42.1% accuracy rate compared to 50%. The experienced provider was accurate 50% of the time in the supraclavicular approach compared to 38.5%. The providers were not able to predict their accuracy regardless of experience. The experienced providers, when compared to those who were less experienced, were more likely to be overconfident, particularly with the anterior and supraclavicular approaches.

CONCLUSION

There was no statistically significant difference between the 3 approaches. The anterior approach was the most accurate, independent of the experience level of the provider. The posterior approach produced the lowest level of confidence regardless of experience. The experienced providers were not able to accurately predict the results of their injections, and were more likely to be overconfident with the anterior and supraclavicular approaches.

Magnetic resonance-guided interventions of large and small joints

Magnetic resonance (MR)-guided interventions of large and small joints are feasible and safe procedures offering several advantages compared with standard guiding techniques. Nevertheless, MR-guided interventions are not routinely performed in daily practice apart from a few centers. Accurate injections are crucial for clinical outcome in diagnostic arthrography as well as therapeutic joint injections. In particular, palpatory joint puncture was shown to be inaccurate or uncertain in a substantial percentage of injections of the shoulder, the hip, and the knee. Magnetic resonance imaging offers respective merits of a cross-sectional technique with high soft-tissue contrast. Exact depiction of structures, which should be preserved, such as the labrum, should be aimed for. Areas with complex anatomy can be approached by adapting the right imaging plane(s) because of multiplanar capacity. Lack of ionizing radiation for patients is of growing interest particularly in young patients with repeated interventions. Magnetic resonance guidance alone allows an "all-in-one" MR arthrography combining precise targeting with high-field-strength imaging. Modern short-bore and open-bore high-field-strength systems offer a good comfort for patients as well as clinicians and enhance patient positioning options such as supine or prone position. Thus, a tailored approach such as a posterior technique for suspected anterior lesions in shoulder MR arthrography is possible.In this article, we describe the advantages and limitations of MR guidance in joint interventions with focus on shoulder and hip interventions. We review the requirements for needle material and MR sequences, discuss several different techniques developed to date, and present current results in clinical outcome.

Percutaneous foot joint needle placement using a C-arm flat-panel detector CT

PURPOSE

Image guidance is valuable for diagnostic injections in foot orthopaedics. Flat-detector computed tomography (FD-CT) was implemented using a C-arm, and the system was tested for needle guidance in foot joint injections.

METHODS

FD-CT-guided joint infiltration was performed in 6 patients referred from the orthopaedic department for diagnostic foot injections. All interventions were performed utilising a flat-panel fluoroscopy system utilising specialised image guidance and planning software. Successful infiltration was defined by localisation of contrast media depot in the targeted joint. The pre- and post-interventional numeric analogue scale (NAS) pain score was assessed.

RESULTS

All injections were technically successful. Contrast media deposit was documented in all targeted joints. Significant relief of symptoms was noted by all 6 participants.

CONCLUSIONS

FD-CT-guided joint infiltration is a feasible method for diagnostic infiltration of midfoot and hindfoot joints. The FD-CT approach may become an alternative to commonly used 2D-fluoroscopically guidance.

Accuracy of anterolateral versus posterolateral subtalar injection

INTRODUCTION

Injections into the subtalar joint may be performed for diagnostic or therapeutic reasons. The anterolateral approach is most commonly utilised for this purpose. We evaluated the success of an intra-articular puncture by using the anterolateral in comparison to the posterolateral approach.

METHODS

Sixty-eight cadaver adult feet were used for performing injections into the subtalar joint without fluoroscopic or ultrasound guidance. Methylene blue dye was infiltrated into 34 of the 68 subtalar joints through an anterolateral approach and into 34 through an posterolateral approach. An arthrotomy was then performed to confirm the placement of the dye within the joint.

RESULTS

Twenty-three of the anterolateral injections (67.6%) were successful as were 31 of 34 (91.2%) of the posterolateral. The posterolateral approach showed a greater accuracy with a statistically significance (p = 0.016).

CONCLUSION

Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Comparing the anterolateral to the posterolateral approach with regards to the rate of successful intra-articular puncture of the subtalar joint without the use of imaging there is a greater accuracy with the PL with statistically significance.

Accuracy of intra-articular glenohumeral injections: the anterosuperior technique with arthroscopic documentation

PURPOSE

Our objective was to assess the accuracy rate of needle placement with the anterosuperior technique of glenohumeral joint injection that uses familiar palpable superficial landmarks as a guide instead of diagnostic imaging.

METHODS

Between April 2007 and October 2007 at our institution, 42 patients met the study inclusion criteria of being aged 18 years or older and undergoing shoulder arthroscopy. For the injection (performed by 1 surgeon), anesthetized patients were placed in the beach-chair position with the arm in adduction and internal rotation. The surgeon was allowed to redirect the needle only once without withdrawing the needle from the entry site. After injection, arthroscopic confirmation of needle position in the joint and the presence of backflow from the posterior portal cannula were used to determine accuracy and the relation of the needle to adjacent anatomy.

RESULTS

Of the 42 injections, 38 needles were inserted accurately into the glenohumeral joint (91% accuracy rate), most through the rotator interval (21) or the long head of the biceps tendon (9). Four needles were placed inaccurately into the anterior synovium and subacromial space. Adhesive capsulitis was the diagnosis in 3 of those 4 shoulders but in only 5 of the 38 shoulders in the group with accurate placement (P < .05). Body mass index was not statistically different between the accurate and inaccurate injection groups (P > .05).

CONCLUSIONS

Anterosuperior glenohumeral joint injection without image guidance provides an accuracy rate of 91%. The anterosuperior technique for glenohumeral injections yields an accuracy rate higher than that of the standard anterior techniques and comparable to that of posterior injection.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

[Ultrasound and arthritis]

Musculoskeletal ultrasonography (US) is an established and validated imaging technique in rheumatology. Ultrasonography is able to directly visualize soft tissue pathologies such as synovial tissue changes. Pathological findings in superficial cartilage, bone lesions and synovial tissue changes in the context of rheumatoid arthritis, spondyloarthritis or crystal arthropathies may only be seen by sonography or detected earlier by ultrasonography compared to conventional imaging techniques. The activity of an inflammatory arthropathy can be visualized using Doppler and power Doppler US. US is helpful in the detection of early inflammatory changes, particularly in patients with undifferentiated arthritis and/or unremarkable conventional radiography. In addition to diagnosis in early arthritis and monitoring of therapy in rheumatoid arthritis, sonography is able to detect pivotal pathologies in spondyloarthritis and crystal deposition diseases such as gout, pseudogout and apatite deposition disease. Ultrasound-guided diagnostic and therapeutic interventions are characterized by their excellent accuracy and improvement of clinical effectiveness compared to unguided procedures. In conclusion, ultrasonography plays a pivotal role in the assessment and monitoring of therapy in rheumatic diseases.

Pain in osteochondral lesions

Pain is the key symptom of patients suffering from osteochondral lesions (OCLs) of the ankle joint. Routine radiographic imaging methods for diagnosis and staging of OCL fail to visualize the pain-inducing focus within the joint. SPECT-CT (Single-photon emission computed tomography-computed tomography) is a new hybrid imaging technique allowing exact digital fusion of scintigraphic and computer tomographic images. This allows precise localization and size determination of an OCL within the joint. Using this novel imaging method, we conducted a study to evaluate the correlation between pathological uptake within an OCL and pain experienced by patients suffering from this condition; 15 patients were assessed in the orthopaedic ambulatory clinic for unilateral OCL of the ankle joint. Pain status was measured with the Visual Analogue Scale (VAS). A SPECT-CT was performed. All patients underwent CT-guided ankle injection with a local anesthetic and iodine contrast medium. The VAS score assessed immediately postinfiltration was compared with the preinterventional VAS score obtained in the outpatient clinic. Pain relief was defined as a reduction of the VAS score to ≤50% of the preinterventional score, if expected immediately after infiltration. Pain relief was found in all 15 patients. The results of our study show that there is a highly significant correlation between pain and pathological uptake seen on SPECT-CT, indicating that pathologically remodeled bone tissue is an important contributor to pain in OCL. Adequate addressing of involved bone tissue needs to be taken into consideration when choosing a surgical treatment method.

The highly accurate anteriolateral portal for injecting the knee

Background

The extended knee lateral midpatellar portal for intraarticular injection of the knee is accurate but is not practical for all patients. We hypothesized that a modified anteriolateral portal where the synovial membrane of the medial femoral condyle is the target would be highly accurate and effective for intraarticular injection of the knee.

Methods

83 subjects with non-effusive osteoarthritis of the knee were randomized to intraarticular injection using the modified anteriolateral bent knee versus the standard lateral midpatellar portal. After hydrodissection of the synovial membrane with lidocaine using a mechanical syringe (reciprocating procedure device), 80 mg of triamcinolone acetonide were injected into the knee with a 2.0-in (5.1-cm) 21-gauge needle. Baseline pain, procedural pain, and pain at outcome (2 weeks and 6 months) were determined with the 10 cm Visual Analogue Pain Score (VAS). The accuracy of needle placement was determined by sonographic imaging.

Results

The lateral midpatellar and anteriolateral portals resulted in equivalent clinical outcomes including procedural pain (VAS midpatellar: 4.6 ± 3.1 cm; anteriolateral: 4.8 ± 3.2 cm; p = 0.77), pain at outcome (VAS midpatellar: 2.6 ± 2.8 cm; anteriolateral: 1.7 ± 2.3 cm; p = 0.11), responders (midpatellar: 45%; anteriolateral: 56%; p = 0.33), duration of therapeutic effect (midpatellar: 3.9 ± 2.4 months; anteriolateral: 4.1 ± 2.2 months; p = 0.69), and time to next procedure (midpatellar: 7.3 ± 3.3 months; anteriolateral: 7.7 ± 3.7 months; p = 0.71). The anteriolateral portal was 97% accurate by real-time ultrasound imaging.

Conclusion

The modified anteriolateral bent knee portal is an effective, accurate, and equivalent alternative to the standard lateral midpatellar portal for intraarticular injection of the knee.

Trial Registration

ClinicalTrials.gov: NCT00651625

Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review

BACKGROUND

Joint injections and aspirations are used to reduce joint pain and decrease inflammation. The efficacy of these injections is diminished when they are placed inadvertently in the wrong location or compartment. The purpose of this study was to determine whether the use of varying sites or imaging techniques affects the rate of accurate needle placement in aspiration and injection in the shoulder, elbow, and knee.

HYPOTHESES

(1) Accuracy rates of different joint injection sites will demonstrate variability. (2) Injection accuracy rates will be improved when performed with concomitant imaging.

STUDY DESIGN

Systematic review of the literature.

METHODS

Studies reporting injection accuracy based on image verification were identified through a systematic search of the English literature. Accuracy rates were compared for currently accepted injection sites in the shoulder, elbow, and knee. In addition, accuracy rates with and without imaging of these joints were compared.

RESULTS

In the glenohumeral joint, there is a statistically higher accuracy rate with the posterior approach when compared with the anterior approach (85% vs 45%). Injection site selection did not affect accuracy for the subacromial space, acromioclavicular joint, elbow, or knee. The use of imaging improved injection accuracy in the glenohumeral joint (95% vs 79%), subacromial space (100% vs 63%), acromioclavicular joint (100% vs 45%), and knee (99% vs 79%).

CONCLUSION

Injection accuracy rates are significantly higher for the posterior approach compared with the anterior approach for the glenohumeral joint. Similarly, the accuracy rates are also higher when imaging is used in conjunction with injection of the glenohumeral joint, subacromial space, acromioclavicular joint, and knee.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the ankle region. A descriptive interventional study

BACKGROUND

The ankle region is frequently involved in juvenile idiopathic arthritis (JIA) but difficult to examine clinically due to its anatomical complexity. The aim of the study was to evaluate the role of ultrasonography (US) of the ankle and midfoot (ankle region) in JIA. Doppler-US detected synovial hypertrophy, effusion and hyperemia and US was used for guidance of steroid injection and to assess treatment efficacy.

METHODS

Forty swollen ankles regions were studied in 30 patients (median age 6.5 years, range 1-16 years) with JIA. All patients were assessed clinically, by US (synovial hypertrophy, effusion) and by color Doppler (synovial hyperemia) before and 4 weeks after US-guided steroid injection.

RESULTS

US detected 121 compartments with active disease (joints, tendon sheaths and 1 ganglion cyst). Multiple compartments were involved in 80% of the ankle regions. The talo-crural joint, posterior subtalar joint, midfoot joints and tendon sheaths were affected in 78%, 65%, 30% and 55% respectively. Fifty active tendon sheaths were detected, and multiple tendons were involved in 12 of the ankles. US-guidance allowed accurate placement of the corticosteroid in all 85 injected compartments, with a low rate of subcutaneous atrophy (4,7%). Normalization or regression of synovial hypertrophy was obtained in 89%, and normalization of synovial hyperemia in 89%. Clinical resolution of active arthritis was noted in 72% of the ankles.

CONCLUSIONS

US enabled exact anatomical location of synovial inflammation in the ankle region of JIA patients. The talo-crural joint was not always involved. Disease was frequently found in compartments difficult to evaluate clinically. US enabled exact guidance of steroid injections, gave a low rate of subcutaneous atrophy and was proved valuable for follow-up examinations. Normalization or regression of synovial hypertrophy and hyperemia was achieved in most cases, which supports the notion that US is an important tool in the management of ankle involvement in JIA.

The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee

Although intraarticular injections are important to the management of rheumatoid arthritis, there are few studies regarding the cost-effectiveness of alternative injection techniques. This randomized controlled study addressed the cost-effectiveness of two different low-cost, anatomic landmark palpation-directed intraarticular injection techniques. Ninety-six symptomatic rheumatoid knees were randomized to two different low-cost, palpation-guided intraarticular injection techniques utilizing (1) a conventional syringe or (2) a mechanical syringe, the RPD (the reciprocating procedure device). Three milliliters of 1% lidocaine were used to anesthetize the synovial membrane, followed by arthrocentesis and hydrodissection, and injection of 80 mg of triamcinolone acetonide utilizing the one-needle two-syringe technique. Baseline pain, procedural pain, aspirated fluid volume, pain at outcome (2 weeks and 6 months), responders, reinjection rates, cost/patient/year, and cost/responder/year were determined. Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). Both techniques significantly reduced pain scores at outcome from baseline (P < 0.001). The mechanical syringe technique resulted in a greater volume of aspirated fluid (P < 0.01), a 38% reduction in procedural pain (P < 0.001), a 24% reduction in pain scores at outcome (P < 0.03), an increase in the responder rate (P < 0.025), 33% increase in the time to next injection (P < 0.001), 23% ($35 US) reduction in cost/patient/year for a patient treated in a physician office (P < 0.001), 24% reduction ($26 US) in cost/patient/year for a hospital outpatient (P < 0.001), and 51% ($151 US) reduction in cost/responder/year (P < 0.001). The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee can be improved significantly with low-cost alternations in technique.

Adverse events from diagnostic and therapeutic joint injections: a literature review

This review article classifies the various adverse reactions arising from intra-articular injections by severity, diagnostic category, and whether they are due to corticosteroid, local anesthetic or viscosupplementation injections. Life-threatening and serious adverse events from intra-articular injections are rare and range from local complications to systemic afflictions. Measures to reduce the likelihood of an adverse event occurring are outlined and patients with significant features in their clinical histories, predisposing them to adverse events, are highlighted.

Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis

BACKGROUND

Intra-articular injection is effective for osteoarthritis, but the best single injection strategy is not known, nor are there established predictors of response. The objectives of this study were to assess and predict response to a single ultrasound-guided injection in moderate to severe hip osteoarthritis.

METHODS

77 hip osteoarthritis patients entered a prospective, randomised controlled trial, randomised to one of four groups: standard care (no injection); normal saline; non-animal stabilised hyaluronic acid (durolane) or methylprednisolone acetate (depomedrone).

MAIN OUTCOME MEASURES

Numerical rating scale (NRS 0-10) 'worst pain', Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain/function. Potential predictors of response (including radiographic severity, ultrasound synovitis and baseline symptom severity) were examined using univariate logistic regression analysis and Fisher's exact test.

RESULTS

NRS pain, WOMAC pain and function improved significantly for the steroid arm alone. Effect sizes at week 1 were striking: NRS pain 1.5, WOMAC pain 1.9 and WOMAC function 1.3. Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society responder criteria identified 22 responders (intention-to-treat): steroid 14 (74%; number needed to treat, two); saline, four (21%); durolane, two (11%); and no injection, two (10%; χ(2) test between groups, p<0.001). Corticosteroid arm response was maintained over 8 weeks (summary measures analysis of variance, p<0.002 for NRS pain). Synovitis was a significant predictor of response at weeks 4 and 8 (p<0.05, Fisher's exact test; week 4 OR 16.7, 95% CI 1.4 to 204).

CONCLUSIONS

Ultrasound-guided corticosteroid injections are highly efficacious; furthermore synovitis on ultrasound is a biomarker of response to injection.

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)

Intra-articular drug delivery: the challenge to extend drug residence time within the joint

The rationale behind developing sustained release microsphere formulations of non-steroidal anti-inflammatory drugs (NSAIDs) administered via the intra-articular (IA) route is to minimise the systemic bioavailability and attendant side-effects associated with oral drug administration. Overall dose is reduced whilst therapeutic benefit within the joint is maintained. The potential benefits of IA therapy for osteoarthritis (OA) are not achieved using currently available medications and delivery vehicles due to the rapid clearance of therapeutic substances from the synovial space. There is a need for sustained release delivery systems if the potential of IA drug administration is to be realised. Rationally designed microspheres taken up by synovial macrophages offer a strategy to sustain drug delivery within the joint, and to deliver NSAIDs directly to pivotal inflammatory cells. The efficacy of microsphere candidates may be evaluated in large animal models of OA. The principles of IA microsphere drug delivery may also be applicable to other classes of drugs.

Shoulder pain

INTRODUCTION

Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment, topical drug treatment, local injections, non-drug treatment, and surgical treatment? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound.

Accuracy of anterior glenohumeral injections: a cadaver study

PURPOSE

Intra-articular glenohumeral injections have an important role for therapeutic benefit and diagnostic information. Therefore, it is very important that the injected material should reach its desired target. This study assessed the accuracy of an anterior intra-articular injection in fresh cadavers.

METHODS

A total of 50 shoulders of 25 fresh cadavers were included in the study. Anterior placement of a spinal needle using a location just 1 cm lateral to the coracoid, without radiographic assistance were performed. After the needle was placed and estimated to be intra-articular 1 cc of acrylic dye was injected into the joint to determine accuracy of position.

RESULTS

Ninety-six percent of injections were accurately administered into the glenohumeral joint and 4% in the surrounding soft tissues and capsule.

CONCLUSION

Based on our cadaveric study, an unassisted anterior injection to the glenohumeral joint could be accurately placed.

Intra-articular injection of the acromioclavicular joint

Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure. A total of 76 cadaver acromioclavicular joints were injected with a solution containing methyl blue and subsequently dissected to distinguish intra- from peri-articular injection. In order to assess the importance of experience in achieving accurate placement, half of the injections were performed by an inexperienced resident and half by a skilled specialist. The specialist injected a further 20 cadaver acromioclavicular joints with the aid of an image intensifier. The overall frequency of peri-articular injection was much higher than expected at 43% (33 of 76) overall, with 42% (16 of 38) by the specialist and 45% (17 of 38) by the resident. The specialist entered the joint in all 20 cases when using the image intensifier. Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection.

Does the anteromedial or anterolateral approach alter the rate of joint puncture in injection of the ankle?

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint.

Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances.

The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review

OBJECTIVES

To determine the effectiveness of corticosteroid injections compared with physiotherapeutic interventions for the treatment of adhesive capsulitis/frozen shoulder.

DATA SOURCES

The electronic databases MEDLINE, EMBASE, CINAHL and AMED were searched up to Week 23 2009. Additional database searching included the Cochrane Central Register of Controlled Clinical Trials, the Physiotherapy Evidence Database (PEDro), the National Research Register and the National Recognition Information Centre, also up to Week 23 2009.

REVIEW METHODS

All English-language studies were eligible for inclusion if they showed evidence of random allocation of subjects to either a corticosteroid injection group or a physiotherapeutic intervention group. Studies were considered for inclusion if participants had a stated diagnosis of adhesive capsulitis/frozen shoulder or restriction of passive or active movement in two or more planes. The primary outcomes of interest were pain, external rotation and shoulder disability/function. Quality assessment was assessed using the PEDro scale. Standardised mean differences and effect estimates were calculated for the outcomes of pain, external rotation and shoulder disability at various follow-up periods.

RESULTS

Six studies were deemed eligible for inclusion in the final review. All had evidence of random allocation to either an injection group or a physiotherapeutic intervention group. There were some differences between the studies with regard to both the corticosteroid injections and physiotherapeutic interventions. Standardised mean differences and effect estimates were calculated for three of the included studies at various follow-up periods. There was a medium effect for corticosteroid injections compared with physiotherapeutic interventions for the outcomes of pain, passive external rotation and shoulder disability at 6 weeks. There was only a small effect in favour of corticosteroid injections for pain, passive external rotation and shoulder disability at 12 to 16 weeks and 26 weeks, and pain and shoulder disability at 52 weeks.

CONCLUSION

The results of this review suggest that corticosteroid injections have greater effect in the short term compared with physiotherapeutic interventions. This decreased over time, with only a small effect in favour of injections in the longer term. The results of this review must be interpreted with some caution due to the limited number of studies and differences in the interventions between the studies.

Feasibility of sonography for intra-articular injections in the knee through a medial patellar portal

OBJECTIVE

The purpose of this study was to investigate the feasibility of using real-time high-resolution sonography to guide an injection needle into the intra-articular space within the knee.

METHODS

Eighty-nine patients with radiographically confirmed knee osteoarthritis (Kellgren-Lawrence grade 2 or 3) without an effusion were included. After sonographically guided or blind injection of hyaluronic acid (HA) and contrast dye through a medial patellar portal (MPP) into the knee joint, a radiographic image was made to ascertain whether the injected material had reached the intra-articular space.

RESULT

Sonographically guided injections of HA into the knee joint had a significantly greater accuracy rate (95.6%) than blind injections (77.3%; P = .01).

CONCLUSIONS

Intra-articular injections via an MPP using sonographic guidance may raise the accuracy rate in knee joint injections.

An orthopedic injection training instrument using flow impedance to indicate needle tip locations

OBJECTIVE

The project aimed to design an instrument that can provide visual, quantitative feedback to medical students and help them develop intuitive, tactile-based injection skills.

METHODS

The instrument uses force and displacement sensors to find flow impedance, the ratio of the pressure applied to fluid in the syringe to the fluid flow rate, of different tissues. A software program utilizes these flow impedances to identify needle tip location-either joint or tendon. Injection experiments with pork feet were completed to collect flow impedance data when the needle tip was located in joint or tendon. Injections used deionized water and aqueous pullulan solutions to study the instrument's effectiveness when medical therapies of different viscosities are injected. For each solution, at least 13 injections were conducted. The mean and standard deviation of the flow impedances from injections with each solution were obtained.

RESULTS

In all experimental cases, the flow impedance demonstrated by the tendon is a number of times higher than that of the joint cavity: the impedance ratios (tendon to joint cavity) for water, 3 w/w% pullulan, and 15 w/w% pullulan are 74, 62, and 6, respectively.

CONCLUSIONS

The results confirmed the concept of using flow impedance to index the needle tip location-whether the tip is positioned in joint or tendon. This instrument's user interface can serve as a training aid for medical students and infrequent operators.