Ultrasound-guided Intra-articular Injection Research Articles

Clinical study of ultrasound-guided intra-articular injection of autologous platelet rich plasma for the treatment of lumbar facet joint syndrome

Objective To investigate the clinical efficacy of ultrasound-guided intra-articular injection of autologous platelet rich plasma (PRP) for lumbar facet joint. Methods A total of 40 patients with back pain caused by lumbar facet joint syndrome were enrolled in this study according to the inclusion criteria. They were assigned into two groups (n=20) using the method of random number table to receive the treatment of intra-articular injection of autologous PRP (P group) and glucocorticoid combined with local anesthetic treatment (S group). The therapeutic effects at postoperative (immediately, 1 week, 1 month, 3 months, 6 months) were evaluated by using the Visual Analogue Scale (VAS) score, remission rate of pain [(VAS score before operation-VAS score after operation)/VAS score before operation] and the number of patients with pain relief rate (≥50%). In addition, the adverse reactions, such as aggravation of pain, symptoms of local or systemic infection, symptoms related to nerve injury, hemorrhage and fever from the immediately end after injection to one week after treatment of the two groups were also compared. Results The S group has lower VAS score, higher pain relief rate and more numbers of patients with pain relief rate≥50% than that of P group at postoperative (immediately, 1 week, 1 month)(P<0.05). However, the P group has lower VAS score, higher pain relief rate and more numbers of patients with pain relief rate≥50% than that of S group at 3 months and 6 months after operation (P<0.05). Both groups didn′t show the adverse reactions immediately and 1 week after operation. Conclusions The clinical efficacy of ultrasound-guided intra-articular injection of autologous PRP for lumbar facet joint is not better than glucocorticoid combined with local anesthetic injection at the time of end of operation, 1 week and 1 month after the treatment, but is better than the effect at the time points of 3 months and 6 months after the treatment. Key words: Lumbar facet joint syndrome; Platelet rich plasma; Glucocorticoid

The Safety of Hip Arthroscopy within 3 Months of an Intra-Articular Injection.

Ultrasound-guided intra-articular hip injections have become a mainstay in the diagnosis and treatment of various hip disorders. Concern arises with regard to the chronological proximity of an injection to subsequent arthroscopy. Thus, the purpose of this study was to report the risk of postoperative infections among patients who have undergone an intra-articular corticosteroid injection within 3 months of hip arthroscopy. In-office, ultrasound-guided, intra-articular hip injections were first performed at this center in 2011. Corticosteroid is used for therapeutic purposes in the presence of painful hip conditions to reduce joint symptoms, either to allow for more effective supervised physical therapy or simply as a last line of nonoperative management. A retrospective review of patient records was performed, identifying all patients who had undergone arthroscopy and had received an intra-articular injection of corticosteroid at this institution within 3 months of the surgical procedure. Five hundred patients underwent an ultrasound-guided intra-articular injection of corticosteroid within 3 months of a hip arthroscopy. The mean age was 37.6 years (range, 14 to 74 years), with 112 male patients and 388 female patients. The mean time between the injection and the arthroscopy was 59 days (range, 15 to 92 days). There were no postoperative infections. When both the injection and the procedure are performed in a tertiary referral center, an ultrasound-guided intra-articular injection of corticosteroid within 3 months prior to arthroscopy, at a mean time of 59 days, resulted in no postoperative infections among 500 cases and can represent an acceptably low rate of complication. To our knowledge, this is the largest reported series on this subject. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Accuracy of Ultrasound-Guided versus Landmark-Guided Intra-articular Injection for Rat Knee Joints

Our aim was to test the effectiveness of ultrasound-guided intra-articular (IA) injection into the knee joint of rodents by an inexperienced operator compared with standard landmark-guided IA injections by a trained injector. Fifty landmark-guided and 46 ultrasound-guided IA injections in 49 rats were analyzed. Animal positioning and injection protocol were designed for use with the ultrasound system. Injection delivery was verified with a secondary imaging modality. We compared the success of IA injections by method (landmark and ultrasound-guided), adjusting for all other confounding factors (age, weight, experience, laterality and presence of surgery). Ultrasound-guided injections had higher success rates overall (89% vs. 58%) and helped to reduce the number of failed attempts per injection. None of the cofounding factors influenced the success of injection. In conclusion, we found higher accuracy for ultrasound-guided IA injection delivery than the traditional landmark-based injection method and also the technical feasibility for untrained personnel.

Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton–Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.

Ultrasound-Guided Intra-Articular Injection of the Hip: The Nashville Sound

Ultrasound-guided intra-articular injection has become a mainstay in the diagnosis and treatment of a variety of hip disorders. It is the single greatest adjunct to history and examination in the clinical assessment of hip problems and has substantial therapeutic value in the conservative management of symptomatic disorders, especially when used in conjunction with supervised physical therapy.

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

When is indicated viscosupplementation in hip osteoarthritis?

Background and aim: The incidence of hip osteoarthritis (OA) is increasing in parallel with the aging of the population. The aim of this study is to report the efficacy of an ultrasound-guided intra-articular (IA) hip injection of a single dose of high-weight hyaluronic acid (HA) (2500 kDa) at a follow-up of 12 months. Materials and Methods: 226 patients older than 40 years of age affected by painful hip OA (Kellgren-Lawrence stage 1-2-3) were treated from January 2012 to December 2015 with viscosupplementation. Patients were clinically evaluated before injection (T0) and after 3 months (T3), 6 months (T6) and 1 year (T3) through the WOMAC scale and Harris Hip Score (HHS). Results: During the follow-up period no patients underwent to hip surgery or need adjunctive IA injection of HA. No adverse effects were registered. An improvement in WOMAC and HHS was observed in all patients after treatment. Results showed that patients with grade 2 of osteoarthritis had the higher delta of change in the scores. Discussion: Ultrasound-guided with high weight IA HA injection could be a possibility of treatment in the symptomatic osteoarthritic hip. Subjects with a moderate grade of osteoarthritis (Kellgren-Lawrence stage 2) represent the group that could report the maximum benefits from viscosupplementation. (www.actabiomedica.it)

Use of Ultrasound for Joint Dislocation Reduction in an Austere Wilderness Setting: A Case Report

Point-of-care ultrasound has been shown to have a demonstrable impact in the austere/out-of-hospital environment. As ultrasounds become more affordable and portable, a myriad of uses in austere environments are becoming recognized. We present a case of a stranded hiker with an ultrasound-confirmed glenohumeral joint dislocation who underwent ultrasound-guided intra-articular lidocaine injection and ultrasound-confirmed reduction. This procedure allowed the patient to hike out under his own power, avoiding the potential dangers of extrication to both patient and rescuers. We believe this case demonstrates the feasibility and utility of ultrasound in the out-of-hospital environment both procedurally and diagnostically.

A Three-dimensional Printed Low-cost Anterior Shoulder Dislocation Model for Ultrasound-guided Injection Training.

Anterior shoulder dislocations are the most common, large joint dislocations that present to the emergency department (ED). Numerous studies support the use of intraarticular local anesthetic injections for the safe, effective, and time-saving reduction of these dislocations. Simulation training is an alternative and effective method for training compared to bedside learning. There are no commercially available ultrasound-compatible shoulder dislocation models. We utilized a three-dimensional (3D) printer to print a model that allows the visualization of the ultrasound anatomy (sonoanatomy) of an anterior shoulder dislocation.We utilized an open-source file of a shoulder, available from embodi3D® (Bellevue, WA, US). After approximating the relative orientation of the humerus to the glenoid fossa in an anterior dislocation, the humerus and scapula model was printed with an Ultimaker-2 Extended+ 3D® (Ultimaker, Cambridge, MA, US) printer using polylactic acid filaments. A 3D model of the external shoulder anatomy of a live human model was then created using Structure Sensor®(Occipital, San Francisco, CA, US), a 3D scanner. We aligned the printed dislocation model of the humerus and scapula within the resultant external shoulder mold. A pourable ballistics gel solution was used to create the final shoulder phantom.The use of simulation in medicine is widespread and growing, given the restrictions on work hours and a renewed focus on patient safety. The adage of “see one, do one, teach one” is being replaced by deliberate practice. Simulation allows such training to occur in a safe teaching environment. The ballistic gel and polylactic acid structure effectively reproduced the sonoanatomy of an anterior shoulder dislocation. The 3D printed model was effective for practicing an in-plane ultrasound-guided intraarticular joint injection.3D printing is effective in producing a low-cost, ultrasound-capable model simulating an anterior shoulder dislocation. Future research will determine whether provider confidence and the use of intraarticular anesthesia for the management of shoulder dislocations will improve after utilizing this model.

Commentaries on health services research

Commentaries on health services research

Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial.

Various systematic reviews have recently shown that intra-articular platelet-rich plasma (IA-PRP) can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb. A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III according to the Eaton and Littler classification) was conducted. Group A patients (16 patients) received 2 ultrasound-guided IA-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval. Patients were evaluated prior to and at 3 and 12 months after the second injection using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient's subjective satisfaction. No significant differences between the baseline clinical and demographic characteristics of the 2 groups were identified. After 12 months' follow-up, the IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score (P = 0.015), Q-DASH score (P = 0.025), and patients' satisfaction (P = 0.002). Corticosteroids offer short-term relief of symptoms, but IA-PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic TMJ arthritis.

Corticosteroid injection alone vs additional physiotherapy treatment in early stage frozen shoulders.

AIMTo investigate the additional value of physiotherapy after a corticosteroid injection in stage one or two idiopathic frozen shoulders (FSs).METHODSA two center, randomized controlled trial was done. Patients with a painful early stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional physiotherapy treatment (PT) and the other group did not (non-PT). The primary outcome measure was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes were pain (numeric pain rating scale), range of motion (ROM), quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk.RESULTSTwenty-one patients were included, 11 patients in the non-PT and ten in the PT group, with a mean age of 52 years. Both treatment groups showed a significant improvement at 26 wk for SPADI score (non-PT: P = 0.05, PT: P = 0.03). At the 6 wk follow-up, median SPADI score was significant decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Pain decreased significantly in both groups but no differences were observed between both treatment groups at any time point, except for night pain at 6 wk in favor of the PT group (P = 0.02). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). A significantly greater improvement in abduction (P = 0.03) and external rotation (P = 0.04) was also present in favor of the PT group after 12 wk. RAND-36 scores showed no significant differences in health-related quality of life at all follow-up moments. At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups.CONCLUSIONAdditional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage FSs up to the first three months.

A randomised controlled trial of the clinical and cost-effectiveness of ultrasound-guided intra-articular corticosteroid and local anaesthetic injections: the hip injection trial (HIT) protocol

BackgroundEvidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection.MethodsThe HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants’ ‘average’ follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial.DiscussionTo ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections.Trial registrationISRCTN: 50550256, 28th July 2015.

Comparative Study of Effectiveness of Ultrasound-Guided Suprascapular Nerve Block Versus Intra-Articular Steroid Injection in the Management of Adhesive Capsulitis: A Randomised Controlled Trial in a Tertiary Care Hospital in Northeast India

Comparative Study of Effectiveness of Ultrasound-Guided Suprascapular Nerve Block Versus Intra-Articular Steroid Injection in the Management of Adhesive Capsulitis: A Randomised Controlled Trial in a Tertiary Care Hospital in Northeast India

Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in patients with adhesive capsulitis: Glenohumeral versus subacromial approaches

Aim of the workTo evaluate the efficacy of intra-articular steroid injection of the shoulder joint with exercises in the management of patients with adhesive capsulitis and to compare glenohumeral (GH) versus subacromial subdeltoid (SASD) ultrasound-guided approaches. Patients and methodsForty patients with adhesive capsulitis were randomly divided into 2 groups according to injection approach. Patients received ultrasound-guided intra-articular injection methylprednisolone acetate (40 mg) and 1 ml 2% lidocaine followed by exercise for 12 weeks. Visual analog scale (VAS) for pain, the shoulder pain and disability index (SPADI) and active range of motion (ROM) were assessed before and 12 weeks post-injection. ResultsThe mean age of the patients was 47.3 ± 8.7 years with 12 females and 8 males in each group. After injection, there was a significant improvement of pain (VAS) and SPADI in both groups (p < 0.001). Before injection, SASD bursitis was present in 18 (45%), GH joint effusion in 14 (35%), rotator cuff tendinopathy in 6 (15%), bursitis with effusion in 1 (2.5%) and with supraspinatus tendon calcification in another (2.5%). Both groups significantly equally improved regarding to ROM compared to before injection. Post-injection, the SPADI significantly improved in the SASD group compared to GH; with remarkable improvement in the joint extension, internal and external rotation (p < 0.001). ConclusionIntrarticular steroid injection of the shoulder joint followed by exercises in patients with adhesive capsulitis decreases pain, improves function and ROM with a more favorable response by the GH approach. Ultrasound-guided injection is an accurate, easy and cost-effective approach.

Treatment of Early Hip Osteoarthritis: Ultrasound-Guided Platelet Rich Plasma versus Hyaluronic Acid Injections in a Randomized Clinical Trial

Purpose The aim of this study was to compare the clinical efficacy of ultrasound-guided intra-articular injections of autologous platelet rich plasma (PRP) versus hyaluronic acid (HA) for symptomatic early osteoarthritis (OA) of the hip. Methods A prospective controlled double-blinded randomized trial on 80 patients with hip OA was conducted. The patients were divided in two groups of 40 patients each: group 1 underwent three PRP intra-articular ultrasound-guided injections, whereas group 2 underwent three HA injections. WOMAC, VAS, and Harris Hip Score were evaluated for both groups before and at 6 and 12 months after treatment. Results The two groups were comparable in age, sex, body mass index, and severity of hip OA. Both groups showed a significant improvement from baseline at 6-month and 12-month follow-ups for all the outcome measures. No major complications were observed during the treatment and at follow-ups in both the groups. Conclusion PRP did not offer significantly better results compared with HA in patients with moderate signs of OA, and thus it should not be considered as first-line treatment. Level of Evidence Level II, randomized controlled trial.

Intra-articular onabotulinumtoxinA in osteoarthritis knee pain: effect on human mechanistic pain biomarkers and clinical pain

Objectives: OnabotulinumtoxinA (onabotA) attenuates peripheral nociceptive transduction and consequently neuronal firing. The aim of this mechanistic study was to evaluate the effect of intra-articular (IA) onabotA in patients with painful knee osteoarthritis (OA).Method: We conducted a double-blind, randomized, placebo-controlled, 12-week trial using a single ultrasound-guided IA injection of onabotA (200 U). Patients (N = 121) were randomized to receive onabotA (n = 61) or placebo (n = 60). Mechanistic pain biomarkers and clinical outcomes were used for profiling the effect. The biomarkers were pressure pain thresholds (PPTs) from the knee joint (localized sensitization) and extra-articular sites (widespread sensitization), and wind-up pain (central sensitization). Clinical assessments included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), average daily pain (ADP), patient global impression of change (GIC), and rescue medication. The painDETECT questionnaire (PD-Q) was used for subgrouping patients (nociceptive, neuropathic, and mixed/uncertain).Results: The nociceptive and non-nociceptive groups were identical with respect to all baseline data. No significant differences in clinical efficacy parameters were found between onabotA and placebo in the entire population. The nociceptive group showed significant improvement after IA onabotA at week 8 for all WOMAC outcomes, ADP at weeks 9 and 10, and patient GIC at week 12, and significant reduction in rescue medication counts within each 14-day period at weeks 9 and 10. After 4, 8, and 12 weeks, significant correlations were obtained in the onabotA group between ADP (both the entire group and the nociceptive group) and various sensitization parameters. The nociceptive group showed pronounced effects on widespread sensitization.Conclusions: Intra-articular onabotA given to patients with nociceptive knee OA reduced pain sensitization together with improvement in pain and function.

Clinical Applications of Ultrasound in Osteoarthritis

Osteoarthritis is the most prevalent chronic joint disease. The most common symptoms include joint pain, swelling and stiffness. It is characterized by loss of joint cartilage, which leads primarily to loss of function of the knee and hip joints. However, none of the current clinical methods or approaches has significant value in terms of early diagnosis of osteoarthritis or monitoring of its progression or treatment response. Recently, a number of studies have suggested that ultrasound may be of significant value for early detection and treatment of osteoarthritis. Compared with current clinical methods, ultrasound is a valuable modality owing to its high patient acceptability, overall assessment of osteoarthritic joints, safety, quick performance and absence of radiation. The ultrasound technique has been introduced in the specialty of rheumatology, and is a valuable tool for the assessment of osteoarthritis. It can be used safely to monitor osteoarthritis progression and response to treatment. Osteoarthritis treatment with ultrasound-guided intra-articular injection is an economical and safe local procedure; furthermore, it can be performed accurately and is well-tolerated by patients. Operator-dependent and incomplete visualization of the joint structure are the main limitations in the clinical application of ultrasound in cases of osteoarthritis. Further research is needed in order to examine the role of ultrasound in the management and diagnosis of osteoarthritis.

Efficacy and safety of point-of-care ultrasound-guided intra-articular corticosteroid joint injections in patients with haemophilic arthropathy.

Intra-articular corticosteroid injections are standard of care for managing joint pain secondary to osteoarthritis or rheumatoid arthritis but are rarely used in haemophilic arthropathy. We have introduced and evaluated the efficacy and safety of ultrasound-guided corticosteroid injections for pain relief in patients with haemophilic arthropathy. Ultrasound-guided intra-articular injections performed on haemophilia patients at UCSD between March 2012 and January 2016 were analysed. Needle placement and injection (40 mg triamcinolone; 3-5 mL lidocaine) were performed with musculoskeletal ultrasound and Power Doppler. Analysis included patient demographics, joint-specific parameters such as tissue hypervascularity and effusions, pain relief, and procedure-associated complications. Forty-five injections (14 ankles, 13 elbows, 18 knees) were administered in 25 patients. Advanced arthropathy with hypervascularity and/or effusions was present in 91% and 61% of joints, respectively. Ninety-one per cent of injections resulted in pain relief which was significant in 84% (>30% reduction). Median pain score was reduced from 7 of 10 to 1 of 10 (P < 0.001), usually within 24 h. Median duration of pain relief was 8 weeks (range 1-16 weeks). Haemophilia B patients experienced longer periods of relief, and high Pettersson scores were associated with shorter duration of relief. There were no procedure-associated complications. Repeat ultrasound of eight joints within 4 weeks of injection demonstrated nearly complete resolution of hypervascularity. Point-of-care ultrasound enabled intra-articular corticosteroid injections that provided highly effective, safe, and relatively long-lasting pain relief in haemophilic arthropathy. This approach should be used to improve pain management in haemophilic arthropathy.