Palpation versus ultrasound-guided corticosteroid injections and short-term effect in the distal radioulnar joint disorder: a randomized, prospective single-blinded study

Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society

BACKGROUND

Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians.

METHODS

Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus.

RESULTS

This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection.

CONCLUSIONS

In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Ultrasound of the Ulnar Nerve: A Pictorial Review: Part 2: Pathological Ultrasound Findings

This is the second part of a two-part article in which we focus on the ultrasound (US) appearance of the pathological ulnar nerve (UN) and its main branches. Findings in a wide range of our pathological cases are presented with high-resolution US images obtained with the latest-generation US machines and transducers.

Ultrasound Use by Upper Extremity Surgeons in 2020: A Survey of ASSH Members

BACKGROUND

The use of musculoskeletal ultrasound (US) among hand surgeons appears to be increasing. The purpose of this study was to determine the utilization patterns and attitudes regarding US among American Society for Surgery of the Hand (ASSH) members in 2020 as well as the changes in usage patterns since a previous survey in 2015.

METHODS

In 2020, an updated and expanded 27-question survey was distributed to 4852 members of the ASSH. Questions assessed respondent demographics, training, and practice patterns, and access, utilization, training, and opinions pertaining to US.

RESULTS

A total of 418 surveys (8.6%) were analyzed. Compared to 2015, there was an increase in the percentage of respondents using US for diagnostic purposes (51%-68%), as well as having personal access to US machines (43% to 58%). US use to assist in diagnosing carpal tunnel syndrome increased from 19% to 27%. The most common reason for using US was convenience and practice efficiency, while the most common reasons for not using US was no machine access. In 2020, 33% of respondents performed US-guided injections.

CONCLUSIONS

Compared to 2015, the majority of responding upper extremity surgeons now have personal access to US machines. Utilization of diagnostic US appears to be increasing, and two-thirds of respondents believed that US use will continue to increase among upper extremity surgeons.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

The Efficacy of Intra-Articular Versus Extra-Articular Corticosteroid Injections in the Thumb Carpometacarpal Joint

Purpose

This study evaluated whether the location of steroid deposition (intra-articular vs extra-articular) for thumb carpometacarpal (CMC) joint arthritis affects clinical outcomes.

Methods

We prospectively enrolled 102 hands (82 patients) with thumb CMC joint arthritis. Patients received a CMC joint injection with Triamcinolone and radiopaque contrast. Wrist radiographs were used to visualize the injection location. Patients completed Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) questionnaires and visual analog scale (VAS; scale, 1-100) pain scores before injection and then at 1 week and 1, 3, and 6 months after injection. Generalized linear regression models were constructed to identify variables associated with clinical outcomes.

Results

The rate of intra-articular injection was 80%. No differences were found between the 2 groups in preinjection DASH or VAS scores. After 1 week, both the intra-articular and extra-articular groups showed improvements of DASH (14.2 and 11.2, respectively) and VAS (15.5 and 15.0, respectively) scores. Although both groups were worse at 3 months, the intra-articular group had significantly lower DASH (26.7 vs 37.5, respectively) and VAS (26.5 vs 39.0, respectively) scores than the extra-articular group. There were no differences between the intra-articular and extra-articular groups for DASH (33.8 vs 42.5, respectively) or VAS scores at 6 months. The intra-articular group maintained significant improvements in outcomes for up to 6 months, while the extra-articular group only maintained them for up to 1 month. The Eaton-Littler classification was found to be a predictor of DASH and VAS scores at 3 and 6 months.

Conclusions

Intra-articular injection in the thumb CMC joint provides significantly greater pain relief and functional improvement compared to extra-articular injection at 3 months. Inadvertent extra-articular injection is common and appears to provide short-term pain relief and functional improvement. Some patients receiving intra-articular injections continue experiencing relief for up to 6 months.

Type of study/level of evidence

Therapeutic II.

Radio-carpal wrist MR arthrography: comparison of ultrasound with fluoroscopy and palpation-guided injections

OBJECTIVE

To compare ultrasound- (US), fluoroscopy- (FL), and palpation-guided contrast injection techniques used for dorsal radio-carpal wrist MRA.

MATERIALS AND METHODS

Patients with chronic wrist pain were randomized as to which injection technique they underwent into three groups of 50 participants. Dorsal radio-carpal contrast injection was performed under US, FL guidance (one radiologist for each), or palpation guidance by an orthopedic surgeon. The three techniques were compared by procedure time, success rate, number of attempts needed, frequency and grade of extravasation, joint distension, and MRA image quality. Additionally, any change from baseline wrist pain was recorded using the visual analog scale (VAS) at five time points (immediately, 8 h, 24 h, 48 h, and 1 week) after injection.

RESULTS

One hundred and fifty patients (83 males and 67 females; mean age 29 ± 6.5 years) were included. Success rates for US- and FL-guided injections were 100%, while palpation-guided approach was significantly less successful (72%) (P = 0.02) with significantly more frequent extravasation (56%)(P < 0.001). US guidance was the least time-consuming (6.5 ± 1.6 min) compared to FL guidance (12.5 ± 1.9 min) and palpation guidance (8 ± 1.2 min) (all P < 0.001). The mean number of joint puncture attempts was significantly lower with imaging-guided techniques (1.1 ± 0.24 and 1.2 ± 0.4 for US and FL, P = 0.23) compared to palpation-guided one (1.6 ± 0.8) (P = 0.007). The largest increases in baseline-pain were 8-h post-injection, and US guidance was the least painful at all-time points (all P < 0.05). Joint distension and image quality were significantly better with imaging-guided techniques (P < 0.001 and P = 0.003).

CONCLUSIONS

US-guided radio-carpal injection is a less time-consuming, more tolerable, and successful radiation-free method when compared to FL guidance. Palpation-guided injections require multiple attempts to enter the joint with high failure rates and frequent extravasation.

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

OBJECTIVES

Arthrocentesis is commonly performed in the emergency department, but success rates vary based on location. Presently, there is a paucity of data assessing the utility of ultrasound-guided (USG) medium-sized joint arthrocentesis. The objective of this study was to compare the success of USG and landmark-guided (LMG) medium-sized joint arthrocentesis.

METHODS

This was a single-center, prospective, randomized clinical trial (NCT03327584) of a convenience sample of adult patients who presented to an urban, university hospital with > 105,000 visits annually. Patients with a suspected medium-sized joint effusion (defined as elbow, wrist, or ankle) undergoing arthrocentesis were randomized into LMG or USG using the GE Logiq e linear transducer (4-10 MHz). The following patients were excluded: on anticoagulation, with soft tissue infection overlying the joint, or involving an artificial joint. Statistical analysis included the Fisher exact, Mann-Whitney U-test, and t-test.

RESULTS

Overall, 44 patients were enrolled with 23 patients randomized into the LMG group and 21 patients into the USG arm. USG was significantly better than LMG with an overall success of 94.1% versus 60% for LMG (difference = 34.1%, 95% confidence interval [CI] = 4.90 to 58.83). USG first-pass success was 82.4% versus 46.7% for LMG (difference = 35.7%, 95% CI = 2.76 to 60.37) and a mean of 1.35 attempts versus 2.00 for LMG (difference = 0.65, 95% CI = 0.005 to 1.296). Of the 14 LMG failures, eight had no effusion present on USG crossover. Four patients in the USG group had no effusion present.

CONCLUSIONS

Ultrasound guidance improved first-pass and overall successful arthrocentesis of medium-sized joint effusions.

Short-term Efficacy of Ultrasonographic Guidance for Intra-articular Corticosteroid Injection in Hallux Rigidus: A Single-Blind Randomized Controlled Trial

BACKGROUND

Multiple considerations should be taken before standardizing a clinical procedure such as efficacy, safety, or the cost. The aim of this study was to compare the effects of landmark-guided vs ultrasonography-guided intra-articular injection of corticosteroid into the first metatarsophalangeal joint cavity to reduce pain and dysfunction in patients with hallux rigidus.

METHODS

We carried out a single-blind randomized controlled trial with 2 parallel arms in an outpatient clinic affiliated with a medical university. In total, 50 participants (35 women) with the mean (SD) age of 49.8 (10.3) years were randomly allocated to landmark-guided or ultrasonography-guided groups (each n = 25). Each patient received a single intra-articular injection of 40-mg methylprednisolone plus 1 mL lidocaine into the affected first metatarsophalangeal joint. The primary outcome was joint pain and the secondary outcome was the American Orthopaedic Foot & Ankle Society score. We measured the outcomes at baseline and 2 and 6 weeks after the intervention.

RESULTS

Six weeks after the injections, there were no statistically significant differences between the study groups in pain reduction and increase in the American Orthopaedic Foot & Ankle Society scores (P = .131 and .241, respectively). We did not find any complications for the injections in both groups. There were statistically significant changes within each group in pain and the scores for the landmark (P < .001, and P = .007), and ultrasonography groups (both P < .001).

CONCLUSION

Landmark guidance is as effective as ultrasonographic guidance for intra-articular injection in patients with hallux rigidus. A single intra-articular injection of 40 mg methylprednisolone plus 1 mL lidocaine is an efficient and safe therapeutic measure for decreasing joint pain and maintaining its function, at least for 6 weeks.

LEVEL OF EVIDENCE

Level I, high-quality prospective randomized study.

Treatment Options for Distal Radioulnar Joint Arthritis: Balancing Functional Demand and Bony Resection

The distal radioulnar joint is a complex anatomic structure that allows for a combination of rotation and translation with extrinsic and intrinsic stabilizers that maintain stability through a delicate equilibrium. Traumatic, congenital, inflammatory, and degenerative processes can disturb this sensitive balance, resulting in distal radioulnar joint arthritis. We discuss the joint's anatomy and biomechanics and the clinical approach to the patient. We review the surgical treatment options, expected outcomes, and their shortcomings. Selecting the best surgical intervention often means choosing the procedure with the set of complications and limitations best suited for the specific patient.

Cost-Benefit Analysis of Ultrasonography in the Hand Clinic

BACKGROUND

Despite previous studies demonstrating the benefit of office-based ultrasonography for musculoskeletal evaluation, many hand surgery clinics have yet to adopt this practice. The authors conducted a cost-benefit analysis of establishing an ultrasound machine in a hand clinic.

METHODS

The authors used the Medicare Physician Fee Schedule, Physician/Supplier Procedure Summary, and Physician Compare National Downloadable File databases to estimate provider reimbursement and annual frequency of office-based upper extremity-related ultrasound procedures. Ultrasound machine cost, maintenance fees, and consumable supply prices were gleaned from the literature. The primary outcomes were net cost-benefit difference and benefit-cost ratio at 1 year, 5 years, and 10 years after implementation. Sensitivity analyses were performed by varying factors that influence the net cost-benefit difference.

RESULTS

The estimated total initial expense to establish ultrasonography in the clinic was $53,985. The overall cost-benefit difference was -$49,530 per practice at the end of the first year (benefit-cost ratio, 0.3), -$1049 after 5 years (benefit-cost ratio, 1.0), and $52,022 after 10 years (benefit-cost ratio, 1.4). Benefits primarily accrued because of physician reimbursements. One-way sensitivity analysis revealed machine price, annual procedure volume, and reimbursement rate as the most influential parameters in determining the benefit-cost ratio. Ultrasonography was cost beneficial when the machine price was less than $46,000 or if the billing frequency exceeded six times per week. A societal perspective analysis demonstrated a large net benefit of $218,162 after 5 years.

CONCLUSIONS

Implementation of office-based ultrasound imaging can result in a positive financial return on investment. Ultrasound machine cost and procedural volume were the most critical factors influencing benefit-cost ratio.

Effectiveness and Safety of Triangular Fibrocartilage Complex Injection Regarding Anatomical Landmarks: A Cadaveric Study

Background  Triangular fibrocartilage complex (TFCC) injections can be applied using anatomical landmarks or under the guide of ultrasound (US). US is not always available, and the physician may rely on the anatomical landmarks. Objective  The study aims to evaluate the effectiveness and safety of TFCC injection with anatomic landmarks. Methods  Forty wrist specimens from cadavers were randomly assigned to four rapid blue stain injection groups as follows: Group A: perpendicular to skin with 5 mm depth; Group B: perpendicular to skin with 10 mm depth; Group C: 45-degree angulation to skin surface, oriented from proximal to distal with 10 mm depth; and Group D: 45-degree angulation to skin surface, oriented from distal to proximal with 10 mm depth. TFCC specimens were excised and evaluated with microscopy, and adjacent neurovascular structures were checked for any injury. Results  Injections in group A were more accurate than others, in which 8/10 injections were successful. Group C injections were least accurate in that only 4/10 were successful. The other remaining groups (groups B and D) revealed similar results (5/10 were successful). However, statistical analyses did not show any significant difference ( p -value = 0.35). No injury to neurovascular structures was seen. Conclusion  Needle placement perpendicular to skin with 5 mm depth and just medial to ulnar styloid can be used as an accurate method of palpation-guided technique for TFCC injections.

Ultrasound-guided vs conventional arthrocentesis for management of temporomandibular joint disorders: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to compare outcomes between ultrasound (US)-guided arthrocentesis and conventional arthrocentesis for the management of temporomandibular joint disorders (TMDs).

METHODS

PubMed, Embase, Scopus, BioMed Central, CENTRAL, and Google scholar databases were searched up to April 1 2020 for randomized control trials (RCTs) comparing US-guided and conventional arthrocentesis.

RESULTS

Four RCTs were included. Pooled analysis did not demonstrate any statistically significant difference in pain or maximal mouth opening (MMO) scores after 1 week and 1 month of follow-up between US-guided and conventional arthrocentesis. Studies also reported data on intra-operative needle relocations and operating time but with conflicting results.

CONCLUSION

This study indicates that the use of US during arthrocentesis may not improve postoperative pain and MMO in the short term. Data on intra-operative outcomes are scarce and conflicting for any definitive conclusions. Further high-quality adequately powered RCTs are required to strengthen current evidence.

Assessment of patient satisfaction, functionality, and quality of life after ultrasound-guided knee intervention: a prospective study

OBJECTIVES

The use of ultrasound (US) guidance for the injection and aspiration of joints has improved accuracy. The aim of this study was to determine if differences exist in the level of patient satisfaction, functionality, and the quality of life in adult patients receiving US-guided (USG) versus landmark-guided (LMG) knee procedures.

METHODS

This prospective, randomized study enrolled 41 patients undergoing knee procedures to USG or LMG groups. visual analogue scale (VAS) for pain, knee injury and osteoarthritis outcome score (KOOS), and patient satisfaction score on a 5-point Likert scale were measured pre-procedure, immediate (< 30 min) and late (4-6 weeks) post-procedure.

RESULTS

Thirty-seven patients were included in the final analysis after exclusion of 4 dropouts (18 in LMG arm, 19 in USG arm). Compared with LMG group, patients in the USG group had significantly better improvement in pain immediately (VAS 1.63 ± 1.6 (95% CI 0.91, 2.35) vs 4.05 ± 2.5 (95% CI 2.90, 4.62), p = 0.001) and later post-procedure (VAS 2.68 ± 2.0 (95% CI 1.78, 3.58) vs 6.38 ± 3.8 (95% CI 4.62, 8.14) p = 0.004) and satisfaction scores immediately (4.89 ± 0.3 (95% CI 4.76, 5.02) vs 4.11 ± 1.0 (95% CI 3.65, 4.57), p = 0.002) as well as delayed post-procedure (4.52 ± 0.9 (95% CI 4.12, 4.92) vs 3.38 ± 1.6 (95% CI 2.64, 4.12), p = 0.028).

CONCLUSION

USG knee procedures were associated with higher patient satisfaction, both immediately after the procedure and after 4-6 weeks compared with LMG knee procedures. Key Points •This prospective study is the first one to look at patient satisfaction as an outcome measure after intra-articular steroids knee injections. •USG (US-guided) knee procedures were associated with higher patient satisfaction compared with LMG (landmark-guided) knee procedures. •USG knee procedures resulted in greater improvement in symptoms, pain, and quality of life scales after 4-6 weeks compared with LMG knee procedures.

Efficacy of a non-image-guided diagnostic hip injection in patients with clinical and radiographic evidence of intra-articular hip pathology

The purpose of this study was to determine the likelihood of pain relief, as a measure of accurate diagnosis of intra-articular hip pathology and correct needle placement, with a non-image-guided intra-articular hip injection performed bedside in the clinic. A retrospective study of prospectively collected data was performed in a consecutive cohort of patients diagnosed with symptomatic intra-articular hip pathology who underwent a non-image-guided intra-articular injection in the clinic. All patients had clinical and radiographic evidence of hip impingement, hip instability, chondrolabral pathology, or other causes of intra-articular hip pain. A previously described technique for a non-image-guided hip injection was performed using 7-10 ml of 1% lidocaine for diagnostic evaluation with some patients receiving 2 ml of Kenalog^®-40 if clinically indicated. Ten minutes following each injection, the patient was asked to report the percent improvement in pain (from 0 to 100%) while physical examination and provocative tests were repeated. The final study cohort comprised 142 patients (161 injections). In three cases, patients were either unable to assess or quantify any change in pain level 10 min following the injection. In the remaining 158 hip injections, pain relief was noted in 156 cases (156/158, 98.7%), with at least 70% improvement in pain level noted in 152 cases (152/158, 96.2%). Average pain relief among all 158 injections was 89 ± 16%. A non-image-guided diagnostic intra-articular hip injection yields reliable short-term pain relief, simultaneously endorsing accurate diagnosis of hip pathology and intra-articular needle placement.

APPLICABILITY OF RANDOMIZED TRIALS IN HAND SURGERY: SURVEY STUDY

OBJECTIVE

To assess the applicability of randomized clinical trials and whether certain factors (surgeon experience/journal impact factor) influence their applicability.

METHODS

In this survey study we used the Pubmed/Medline database to select 32 consecutive randomized clinical trials published between 2013 and 2015, involving hand surgery (high/low impact). These studies were independently assessed by 20 hand surgeons (with more or less than 10 years of practice) who answered 4 questions regarding their applicability. Agreement was assessed using Cohen's kappa and comparison of proportions via chi-square statistics. P-value <5% constituted statistical significance.

RESULTS

A total of 640 evaluations were produced, generating 2560 responses. A weak correlation was observed between less and more experienced respondents (kappa <0.2; range 0.119-0.179). Applicability between the least and most experienced respondents was similar (p = 0.424 and p = 0.70). Stratification by journal impact factor showed no greater propensity of applicability (p = 0.29) for any of the groups.

CONCLUSIONS

Low agreement was found between the respondents for the applicability of the randomized studies. Surgeon experience and journal impact do not seem to influence this decision. Level of Evidence II, Prospective comparative study.

Ultrasonography for Hand and Wrist Conditions

Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. Ultrasonography can depict masses and fluid collections, help locate radiolucent foreign bodies, characterize traumatic or overuse tendon or ligament pathology, and help evaluate compressive peripheral neuropathy and microvascular blood flow. Additionally, this modality improves the accuracy of therapeutic intra-articular or peritendinous injections and facilitates aspiration of fluid collections, such as ganglia.

Ultrasound-guided procedures in rheumatology. What is the evidence?

Ultrasound (US) is a cost-effective, noninvasive, and accessible imaging modality that clinicians use at the point of care to assess disease activity and therapeutic efficacy in different rheumatic conditions. It can play a relevant role in invasive procedures performed by the rheumatologist, potentially ensuring a higher degree of accuracy. However, US-guided injections are still underused, and the conventional blind injection the most commonly adopted approach. In this article, we analyze the current evidence supporting the use of US-guided procedures, emphasizing comparative studies between conventional and US-guided procedures and their benefits in the daily rheumatological practice.

Evolving Role of Ultrasound in Therapeutic Injections of the Upper Extremity

Ultrasound machines are creating more refined pictures and becoming more user-friendly and readily accessible. As a result, ultrasound is being increasingly used for therapeutic purposes. One example involves the use of ultrasound guidance in musculoskeletal interventional procedures, such as joint injections, tendon sheath injections, and peripheral nerve blocks. Technical considerations and therapeutic results have been described for multiple locations about the upper extremities, with varying levels of success. The implementation of ultrasound-guided injections in the orthopedist's clinic has therapeutic, financial, and provider role implications. Given these potential benefits, orthopedic providers, both in practice and residency, would benefit from increased exposure and education in ultrasound use. Ultrasound provides the benefit of real-time, dynamic imaging without the radiation exposure of fluoroscopy, and ultrasound-guided injections can be performed in the office, as opposed to the operating room, which is frequently required when using fluoroscopy. A basic knowledge of the principles and terms used in ultrasound is required. With these simple principles, a practitioner can review techniques for specific areas of the musculoskeletal system and begin using ultrasound to guide injections. Many locations for diagnostic and/or therapeutic injections in the upper extremities have improved accuracy and benefit with the use of ultrasound vs blind techniques, although a few have not been shown to have a significant difference in the literature. The educational and professional implications can be significant, but these potential benefits need to be carefully weighed against costs by each orthopedic practice.