Ultrasound-guided versus blind interventions in patellar tendon lesions: a cadaveric study

Ultrasound-guided versus blind arthrocentesis in knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

To summarize the current evidence about effectiveness and accuracy of using ultrasound-guided compared to blind arthrocentesis in the treatment of knee osteoarthritis.

METHODS

Web of Science, the Cochrane Central Register of Controlled Trials, EMBASE, Scopus, PubMed, ClinicalTrials.gov, Wangfang Database, and SinoMed were conducted from their inception to February 2024. Eligible studies included Randomized controlled trials (RCTs) and non-RCTs that compared the ultrasound-guided and blind arthrocentesis in knee osteoarthritis, with outcomes assessed base on pain, function, accuracy, and additional factors such as satisfaction, cost-effectiveness, fluid yield, and synovial membrane thickness.

RESULTS

Twenty-one studies that met the inclusion criteria (1924 patients) were identified. The results indicated that ultrasound-guided arthrocentesis was superior to blind arthrocentesis (10 trials; MD = -0.37; 95% CI = -0.55 to -0.19; P = .000). However, no significant difference was found in function improvement (7 trials; SMD = -0.60; 95% CI = -1.31 to 0.12; P = .101). Ultrasound-guided arthrocentesis also demonstrated better accuracy compared to blind arthrocentesis (RR = 1.26, 95% CI: 1.09-1.46, P = .001). For satisfaction, the result reported ultrasound was better than the blind group (MD = 1.11; 95% CI = 0.67-1.54; P = .000) at immediate post-procedure, and at the 4 to 6 weeks (MD = 0.98; 95% CI = 0.56-1.41; P = .000).

CONCLUSION

In the comprehensive systematic review and meta-analysis of knee osteoarthritis, ultrasound-guided arthrocentesis is superior to anatomic landmark-guided arthrocentesis in terms of pain reduction and accuracy.

Pain Decrement Using Radiofrequency Therapy After Knee Platelet-Rich Plasma Injections Within First 72 h in Active Populations with Patellar Chondropathy

Objective: To determine whether 448 kHz capacitive-resistive monopolar radiofrequency (CRMR) after platelet-rich-plasma (PRP) injections can further reduce pain sensation within the first 72 h in an active population with patellar chondropathy. Methods: One-hundred fifty-three active patients with patellar chondropathy grade II-III were followed for three days after PRP injections with and without CRMR under a control-placebo study. They were clinically evaluated for pain sensation using a visual analog scale ranging from zero (no pain sensation) to ten (highest pain sensation). Pain sensation was described using medians and analyzed through the Friedman and Conover test for within-group comparison (pre-intervention, and 24, 48, and 72 h post-intervention) and the Mann-Whitney test for between-group comparisons (Intervention vs. Placebo) with α = 5% and 1-β = 80%. Results: The placebo group showed statistical significance between pre-intervention and 24 h (Δ = -2.0 pts, p < 0.001), baseline and 48 h (Δ = -2.0 pts, p < 0.001), baseline and 72 h (Δ = -3.0 pts, p < 0.001), 24 h and 48 h (Δ = 0.0 pts, p < 0.016), and 24 h and 72 h (Δ = -1.0 pts, p < 0.001). The radiofrequency group showed statistical significance between baseline and 24 h (Δ = -7.0 pts, p < 0.001), baseline and 48 h (Δ = -7.0 pts, p < 0.001), baseline and 72 h (Δ = -8.0 pts, p < 0.001), 24 h and 72 h (Δ = -1.0 pts, p < 0.001), and 48 h and 72 h (Δ = -1.0 pts, p < 0.001). The placebo and radiofrequency groups were significantly different at 24 h (Δ = 4.0 pts, p < 0.001), 48 h (Δ = 4.0 pts, p < 0.001), and 72 h (Δ = 4.0 pts, p < 0.001). Conclusions: CRMR therapy administered after knee intra-articular injections of PRP within the first 72 h in active populations with patellar chondropathy reduces pain sensation with a median difference of 8.0 pts compared to baseline and 4.0 pts compared to placebo group.

Percutaneous ultrasound-guided needle tenotomy for treatment of chronic tendinopathy and fasciopathy: a meta-analysis

OBJECTIVES

To systematically assess the efficacy of percutaneous ultrasound-guided needle tenotomy (PUNT) in the treatment of chronic tendinopathy and fasciopathy.

METHODS

A comprehensive literature search was performed with the following search terms: tendinopathy, tenotomy, needling, Tenex, fasciotomy, ultrasound-guided, and percutaneous. Inclusion criteria consisted of original studies evaluating pain or function improvement after PUNT. Meta-analyses investigating standard mean differences were performed to assess the pain and function improvement.

RESULTS

Thirty-five studies with 1674 participants (1876 tendons) were enrolled in this article. Of which 29 articles were included in meta-analysis and the remaining 9 articles without enough numeric data were included in descriptive analysis. PUNT significantly alleviated pain with the standard mean difference of 2.5 (95% CI: 2.0-3.0; p < 0.05), 2.2 (95% confidence interval (CI): 1.8-2.7; p < 0.05), and 3.6 (95% CI: 2.8-4.5; p < 0.05) points in short-term, intermediate-term, and long-term follow-up intervals, respectively. It was also associated with marked improvement in function with 1.4 (95% CI: 1.1-1.8; p < 0.05), 1.8 (95% CI: 1.3-2.2; p < 0.05), and 2.1 (95% CI: 1.6-2.6; p < 0.05) points, respectively in short-term, intermediate-term, and long-term follow-ups.

CONCLUSION

PUNT improved pain and function at short-term intervals with persistent results on intermediate- and long-term follow-ups. PUNT can be considered an appropriate minimally invasive treatment for chronic tendinopathy with a low rate of complications and failures.

CLINICAL RELEVANCE

Tendinopathy and fasciopathy are two common musculoskeletal complaints that can cause prolonged pain and disability. PUNT as a treatment option could improve pain intensity and function.

KEY POINTS

• The best improvement in pain and function was achieved after the first 3 months following PUNT and was continued to the intermediate- and long-term follow-ups. • No significant difference was found between different tenotomy methods in terms of pain and function improvement. • PUNT is a minimally invasive procedure with promising results and low complication rates for treatments of chronic tendinopathy.

Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review

PURPOSE

Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections.

METHODS

The published literature was searched through PubMed as well as identifying relevant articles from their citations,  for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included.

FINDINGS

The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged.

IMPLICATIONS

The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.

The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review

OBJECTIVES

To compare percutaneous ultrasound-guided needle tenotomy (PUNT) to alternative treatments for chronic tendinopathy.

MATERIALS AND METHODS

A systematic literature search was performed with the following combination of keywords: ultrasound-guided, percutaneous, needling, tenotomy, Tenex, tendinopathy, and fasciotomy. Original studies comparing PUNT to alternative treatments for chronic tendinopathy were included in this systematic review.

RESULTS

Twelve (n = 12) studies with 481 subjects were included. Two (2/12) articles compared PUNT to surgical tenotomy and concluded that PUNT provides the same outcomes as surgical tenotomy. Six (6/12) studies compared PUNT to platelet-rich plasma (PRP) injections, and two of them found both treatment modalities effective with no significant between-group differences. Three trials claimed that PUNT followed by PRP injections showed superior clinical outcomes compared to PUNT alone. However, the difference at long-term follow-up was statistically significant only in one of them. One study found PUNT superior to PUNT + PRP injection at short-term follow-up, although there were no between-group differences at long-term follow-up. Four (4/12) studies compared PUNT to steroid injection (SI) and showed that SI causes fast (2 weeks) but temporary pain relief, PUNT results in persistent but relatively slower improvement to SI, and the combined procedure has a more rapid and steady reduction in symptoms.

CONCLUSION

PUNT is an effective treatment technique for chronic tendinopathy and should be considered when non-invasive treatments have failed. Effects of PRP and SI are transient and dissipate over time and do not contribute to long-term outcome.

Protective action of ultrasound-guided electrolysis technique on the muscle damage induced by notexin in rats

It is known that exercise can be one of the causes of muscular damage. In recent times, physiotherapists and medical professionals have been employing USGET techniques to stimulate muscle recovery to improve its performance after the injury. We pretend to analyse if the Ultrasound-guided electrolysis (USGET) technique could reduce muscle damage, inflammation, and pain in the present study. Female Wistar rats were assigned to one of three different groups: control (C), notexin (NOT) and notexin with USGET (electrolysis at 6mA) (NOT+USGET). We used the USGT technique, based on electrical stimulation with a continuous current of 4 pulses at an intensity of 6 mA for 5 seconds, conveyed to the muscle. The response was tested with motor function tests. In these tests, we could observe an increase in time and foot faults when crossing a beam in the NOT group compared to C group rats. On the other hand, a significant decrease in both variables was detected in the NOT+USGET compared to the NOT group. Muscle power was measured with a grip strength test, obtaining far better performances in NOT+USGET rats when compared to NOT rats. Moreover, the USGET technique prevented the increase of pro-inflammatory proteins IL-6 and chemokines CCL3 (Chemokine (C-C motif) ligand 3), CCL4 (Chemokine (C-C motif) ligand 4), and CCL5 (Chemokine (C-C motif) ligand 5) with their receptor CCR5 (C-C chemokine receptor type 5), induced by notexin in the quadriceps. At the same time, the study evidenced a decrease in both CCR8 (C-C chemokine receptor type 5,) and NF-ᴋB (nuclear factor- ᴋB) expressions after USGET treatment. On the other hand, we obtained evidence that demonstrated anti-inflammatory properties of the USGET technique, thus being the increase in IL-10 (Interleukin 10) and IL-13 (Interleukin 13) in the NOT+USGET group compared to the NOT group. Furthermore, when applying NSGET after damage, an increase in anti-inflammatory mediators and reduction of pro-inflammatory mediators, which, overall, promoted muscle regeneration, was observed. These results support the idea that the NSGET technique improves muscle recovery after toxic damages, which would justify its employment.

Point-of-care ultrasound in musculoskeletal field

The musculoskeletal field is relatively new in point-of-care ultrasound (POCUS), a modality that has been gaining significance with the evolution of ultrasound (US) equipment and high-frequency probes. Images have become progressively clearer over the past decade, making it possible to diagnose many pathological conditions without exposure to radiation. Ultrasonography reveals many soft tissue pathologies that cannot be visualized using plain radiographs, which have historically been the first choice for the evaluation of musculoskeletal disorders. US saves money and time compared to magnetic resonance imaging (MRI). Although it is difficult to diagnose a disorder inside bone, its surface can be visualized very clearly, and it is also possible to visualize cartilage. Furthermore, with POCUS, it is possible to confirm a disorder and the continuity of the fibrous structures of muscles, tendons, and ligaments. In addition, the understanding of pathological conditions of motor disturbances, such as nerve or muscle/tendon injury, nerve paralysis, adhesions of the tendons, and joint instability, is deepened by observing the movement of these structures. Peripheral nerves, even small branches, can be visualized, and pathological conditions can be pinpointed by observing the nerve morphology, continuity, and relationship with the surrounding tissues. Children can be examined in a safe, relaxed environment, without leaving their parents. In addition, US is significantly different from other modalities in that it can be used for both diagnosis and treatment. Being able to visualize target sites improves safety and route accuracy of needle insertion for injection or puncture. Musculoskeletal POCUS is indispensable in routine medical care and is a technique that medical residents should acquire.