US-guided Injection Research Articles

Charcoal suspension tattoo: new tool for the localization of malignant laterocervical lymph nodes.

We present a retrospective study to evaluate safety and effectiveness of ultrasound (US)-guided tattooing with charcoal of suspicious laterocervical lymph nodes. When an open biopsy of a laterocervical lymph node is needed, the choice of the lymph node to excise and examine is fundamental to avoid rebiopsy. Surgeons tend to choose the most surgical approachable enlarged lymph node that does not always correspond to the one with worst echographic aspect. We present 16 cases of patients with laterocervical adenopathy with inconclusive or non-adequate results at fine needle aspiration cytology addressed to open biopsy. Those patients underwent US-guided preoperative injection of a charcoal suspension inside the lymph node to excise to mark it, and then excisional biopsy was performed. Sixteen marked lesions (100%) were detected intraoperatively and dissected. The injected charcoal was detected intraoperatively in all cases. In 14 patients (87, 5%) it was inside the lesion; in two cases (12, 5%), the charcoal suspension was found in the tissues above the lesion. The procedure was well tolerated in all cases. No major procedure-related complications were encountered. US-guided charcoal tattooing is a new, safe, well-tolerated, and easy-to-perform technique for the marking of US suspicious laterocervical lymph nodes. This preliminary study shows a high technical success rate (76%) and high percentage of intraoperative detection of marked lesions (100%) with a low rate of complications.

US-guided Percutaneous Release of the Trigger Finger by Using a 21-gauge Needle: A Prospective Study of 60 Cases.

Purpose To evaluate the efficacy of ultrasonographically (US)-guided percutaneous treatment of the trigger finger by releasing the A1 pulley with a 21-gauge needle. Materials and Methods This two-part study was approved by the ethics committee, and written consent was obtained from all patients. The first part consisted of 10 procedures on cadaver digits followed by dissection to analyze the effectiveness of the A1 pulley release and detect any collateral damage to the A2 pulley, interdigital nerves, or underlying flexor tendons. The second part was performed during an 18-month period starting in March 2013. It was a prospective clinical study of 60 procedures performed in 48 patients. Outcomes were evaluated through a clinical examination at day 0 and during a 6-month follow-up visit, where the trigger digit was evaluated clinically and the Quick Disabilities of the Arm, Shoulder and Hand outcome measure, or QuickDASH, and patient satisfaction questionnaires were administered. Results No complications were found during the cadaver study. However, the release was considered "partial" in all fingers. In the clinical study, the trigger finger was completely resolved in 81.7% (49 of 60) of cases immediately after the procedure. Moderate trigger finger persisted in 10 cases, and one thumb pulley could not be released. A US-guided corticosteroid injection was subsequently performed in these 11 cases. At 6-month follow-up, only two cases still had moderate trigger finger and there were no late complications. The mean QuickDASH questionnaire score was 4; all patients said they were satisfied. Conclusion US-guided treatment of the trigger finger by using a 21-gauge needle is feasible in current practice, with minimal complications. (©) RSNA, 2016 Online supplemental material is available for this article.

Ultrasound-guided retro-calcaneal bursa corticosteroid injection for refractory Achilles tendinitis in patients with seronegative spondyloarthropathy: efficacy and follow-up study.

Ultrasound (US)-guided corticosteroid injection has been shown to be safe and effective for varied causes of plantar fasciitis; however, its use for Achilles tendinitis is controversial. We studied the efficacy and changes in US findings at Achilles enthesitis after corticosteroid injection in patients with spondyloarthropathy (SpA). Patients with SpA with symptomatic Achilles enthesitis, refractory to 6weeks of full-dose NSAIDs, were offered US-guided local corticosteroid injection. Injected entheses were examined by US (both B mode and power Doppler) at baseline and 6weeks after injection. Standard OMERACT definitions were used to define enthesitis. Achilles tendon thickness >5.29mm, 2cm proximal to insertion in long axis, was considered thickened. Twenty-seven symptomatic Achilles tendons (in 18 patients) were injected with 20mg methylprednisolone under US guidance baseline, and 6-week follow-up US features were compared. All patients reported improvement in pain (VAS) in the affected tendon after injection (p<0.0001). Simultaneously, improvement in local inflammatory changes were noted, in the form of significant reduction in tendon thickness (p<0.0001), vascularity (p<0.0001), peritendinous oedema (p=0.001), bursitis and bursal vascularity (p<0.001 and<0.0001, respectively). There was no change in bone erosions and enthesophyte. None of the patients had tendon rupture or other injection-related complications at 6weeks of follow-up. US-guided local corticosteroid injection is an effective and safe modality for refractory Achilles enthesitis in patients with SpA and leads to reversion of acute changes at entheseal site.

Ultrasound-guided Versus Fluoroscopy-controlled Lumbar Transforaminal Epidural Injections: A Prospective Randomized Clinical Trial.

Recently, most lumbar spine injections have been administered under ultrasound (US) guidance; however, there is no standard method for US-guided lumbar transforaminal epidural injection (TFEI). In this study, we evaluated the accuracy, effect on pain relief, and safety of US-guided lumbar TFEI. A total of 80 patients with low back pain and radicular pain were enrolled. The patients were randomly assigned to either the fluoroscopy (FL) group or the US group. The FL-guided approaches were performed under standardized procedures using the C-arm, whereas the US-guided injections were performed with an US device with a linear probe, and were verified by FL. The needle tip reached the lateral side of the lamina in the axis view and the middle of the adjacent facet joints in the parasagittal view. Afterward, the needle was advanced slightly deeper until the loss-of-resistance test was positive. The success ratio of the US-guided interventions was 85%. The operation time in the US group (518±103 s) was shorter than the FL group (929±228 s) (P<0.05). In addition, the radiation dosage in the US group (2640±906 μGy m²) was lower than in the FL group (8992±2132 μGy m²). There was no significant difference in pain relief between the US and FL groups. No serious complication was observed in any of the patients in either group. Lumbar TFEI under US guidance was feasible, safe, and required less radiation to achieve the same benefit as the FL-guided interventions.

Education and Visual Information Improves Effectiveness of Ultrasound-Guided Local Injections on Shoulder Pain and Associated Anxiety Level: A Randomized Controlled Study.

Local injections are widely used in patients with a painful shoulder. The aim of this study was to evaluate the possible impact of patients' visual information on the effectiveness of ultrasound (US)-guided local injections on anxiety levels and shoulder pain. A total of 151 patients, scheduled for local injection owing to shoulder pain, were randomly assigned into two groups in a consecutive order. Patients in group I (n = 72) were provided information related to US findings and allowed to watch the procedures from the monitor, whereas patients in group II (n = 79) received the injection only without any collaboration. Data were collected from both groups immediately before and after injections through visual analog scale and questionnaire (the State-Trait Anxiety Inventory [STAI] forms 1 and 2). US-guided local injections provided significant improvement of anxiety and pain in both groups, irrespective of providing visual information. Group I and group II comparisons with respect to the visual analog scale, STAI 1, and STAI 2 yielded significant difference only for postinjection STAI 2 in group I (P = 0.006). Intragroup comparisons revealed significant differences between preinjection and postinjection values (group I: visual analog scale, P = 0.001; STAI form 1, P = 0.001; STAI form 2, P = 0.002; group II: visual analog scale, P = 0.001; STAI form 1, P = 0.002; STAI form 2, P = 0.042). There was no significant difference between the groups in terms of postinjection satisfaction levels from the procedures (P = 0.824). Performing US-guided shoulder injections with patient visual information provides positive contributions to coping with pain and anxiety. In particular, the patient collaboration-based US-guided injections have positive consequences on patients' long-standing "trait-anxiety" levels.

Ultrasound-Guided Injection of the Adductor Longus and Pectineus in a Cadaver Model

Background: The close anatomic and functional relationship between the proximal parts of the adductor longus and pectineus muscles produce considerable overlap in symptoms and signs in the inguinal region. To our knowledge, there have been no publications of ultrasound (US)-guided injection techniques into the 2 muscles. Objective: This study sought to describe US-guided injection techniques in the proximal part of the adductor longus and pectineus muscles and to validate whether these techniques deliver injections appropriately to their target muscles in unembalmed cadavers. Study Design: Cadaveric study. Methods: A preliminary trial with 2 unembalmed cadavers provided information on the target sonographic structures of proximal adductor longus and pectineus muscles. Bilateral US-guided intramuscular injections in the proximal adductor longus and pectineus were performed using the remaining 5 unembalmed male cadavers. To avoid confusion of dye location, we did not inject into both the adductor longus and pectineus muscle in the same side. After injections, each specimen was dissected to evaluate the accuracy of injection. Results: Ten injections (5 for the adductor longus muscle and 5 for the pectineus muscle) were performed targeting the proximal parts of muscles in 5 cadaveric specimens. All injections were successful and blue dye was injected accurately at the target area within the adductor longus and the pectineus muscles. No other muscles were injected unintentionally. There were no accidental penetrations and/or injuries at adjacent neurovascular structures as well. Limitation: Despite successful injection of the proximal parts of adductor longus and pectineus, this study did not verify the usefulness of this technique in clinical practice. Conclusions: The results of this study may play a role in the diagnosis and management of patients presenting with chronic pelvic pain syndrome and sports hernia. Key words: Inguinal, injections, ultrasonography, pain, cadaver, pectineus, adductor, pelvis

Inefficacy of ultrasound-guided local injections of autologous conditioned plasma for recent epicondylitis: results of a double-blind placebo-controlled randomized clinical trial with one-year follow-up.

The aim was to assess the efficacy of two intra-tendinous injections of platelet-rich plasma (PRP) on epicondylitis of recent evolution (≤3 months). Our study was a double-blind placebo-controlled randomized trial. Two US-guided injections of either PRP (autologous conditioned plasma) or saline solution were performed with an interval of 4 weeks. The exclusion criterion was previous CS infiltration. Patients were monitored by an independent evaluator blinded to treatment at baseline and 1, 3, 6 and 12 months of follow-up. The primary evaluation criterion was the relative improvement from baseline to 6 months in pain score on visual analog scale (0-10). Secondary criteria were the Roles-Maudsley score and the assessment of pain on isometric contraction of extensor carpi radialis brevis and extensor digitorum communis. Twenty-five patients were randomly assigned to each group. Three patients in each arm dropped out before 6 months. In both groups, the pain score [mean (s.d.)] decreased significantly between two consecutive visits from 6.8 (0.8) (PRP) and 7 (1) (saline) at baseline to 2.5 (1.6) and 1.6 (1.5) (PRP) and to 2.1 (1.6) and 1.8 (2.1) (saline) at 6 and 12 months, respectively. At 6 months, no statistically significant difference was found between groups for relative improvement in pain score [autologous conditioned plasma: -63.2 (22.4%); saline: -69.7 (25.1%); P = 0.24]. No significant difference was found for the secondary criteria. Two US-guided PRP injections for epicondylitis of recent evolution were not more efficacious than saline injections, until 6- and 12-months follow-up. ClinicalTrials.gov; https://clinicaltrials.gov/; NCT02378285.

The thyrohyoid membrane as a target for ultrasonography-guided block of the internal branch of the superior laryngeal nerve

Study objectiveThe objective was to present a proof of concept for a simple and consistently successful ultrasonograpy (US)-guided technique to block the internal branch of the superior laryngeal nerve (iSLN). DesignThis was a volunteer and cadaver anatomy study. SettingThe setting was an anesthesiology department and an anatomy laboratory at a medical school MeasurementsH13-6 MHz US scans were performed in 40 healthy volunteers positioned supine and with extended necks. The goals were to identify the thyrohyoid membrane, measure its depth (in centimeters) using the shortest vertical distance from the skin, and record the scanning time (in seconds) needed to obtain the optimal image.Anatomical dissection was performed with an operating microscope bilaterally on 5 adult cadaver heads, fixed in formalin, to expose the point of iSLN penetration through the thyrohyoid membrane. The distance between the greater horn of the hyoid bone and the nerve entry point into the thyrohyoid membrane was measured. Ultrasonography-guided in-plane injections were performed unilaterally with 22-gauge 50-mm nerve block needles in 3 fresh cadavers with 2-mL lidocaine/methylene blue mixture deposited under direct vision just superficial to the thyrohyoid membrane to evaluate technical feasibility and injectate spread. Main resultsAnatomically, the iSLN was identified in all formalin-preserved cadavers, with hyoid bone greater horn to nerve-membrane interface distances measuring 1.0-2.4 cm (mean, 2.0 cm; SD, 0.5).Sonographically, the iSLN was not visualized, whereas the hyoid bone and the thyrohyoid membrane were visualized in all volunteers. The mean distance from skin to thyrohyoid membrane was 1.69 cm (SD, 0.38). The mean time needed to scan was 15 seconds (SD, 2.3). After US-guided injection, the dye deposition was observed around the iSLN in all cadaver specimens. ConclusionsA simpler and consistently reproducible US-guided iSLN block is feasible using the thyrohyoid membrane as target plane for local anesthetic injection. Clinical trials are needed to determine its effectiveness and safety, needle entry point, trajectory, and local anesthetic volume.

Palpation Versus Ultrasound-Guided Acromioclavicular Joint Intra-articular Corticosteroid Injections: A Retrospective Comparative Clinical Study

Background: Primary osteoarthritis (OA) is the most common cause of pain arising from the acromioclavicular (AC) joint. The true incidence is unknown because of differences in the criteria used to define arthritis in various studies. The proper diagnosis of AC joint OA requires a thorough physical examination, radiographic findings, and a diagnostic local anesthetic injection. Objective: The goal of this study was to assess the effects and safety of ultrasound (US) versus palpation-guided acromioclavicular (AC) joint intra-articular (IA) corticosteroid injection for patients with osteoarthritis (OA) of the AC joint. Study Design: Retrospective, compared clinical study. Setting: University hospital outpatient pain clinic. Method: We retrospectively reviewed the charts of patients with AC joint degenerative OA who had undergone US or palpation-guided AC joint IA corticosteroid injection between January 2012 and December 2013 at our outpatient clinic. One hundred consecutive patients identified from chart review met inclusion criteria. Patients (N = 50) in US guide AC joint IA steroid injection group were administered a mixture of 0.5% lidocaine (1 mL) with triamcinolone (20 mg/mL; 0.5 mL) and radiographic contrast material (0.5 mL) and patients (N = 50) in palpation-guided AC joint IA steroid injection group were administered a mixture of 0.5% lidocaine (1 mL) with triamcinolone (20 mg/mL; 0.5 mL) and 0.5 mL of radiographic contrast material. Results were measured using the Shoulder Pain and Disability Index (SPADI), Verbal Numeric pain Scale (VNS) at rest (VNSar), under local pressure (VNSlp) ,and the arm adduction test (VNSaat) at the joint space area before injections and at one, 3, and 6 months after the injections. Successful treatment occurred when patients obtained significant pain relief (as measured by &gt; 50% improvement in the VNS score and 20 point improvement in the SPADI) at one, 3, and 6 months after the injections. Univariable analysis was performed to evaluate the relationship between possible outcome predictors and therapeutic effect by using a chi-square test. Logistic regression analysis was performed to assess whether injection method, injection accuracy, patients’ age, gender, and duration of the disease were independent predictors of successful outcome. Results: SPADI, VNSaat, VNSlp, and VNSar improved at one, 3, and 6 months after the injections in both groups. There was a statistically significantly greater improvement in the VNSlp score and SPDAI at 6 months and in the VNSaat score at 3 months and 6 months for US-guided group as compared with the palpation group. Successful treatment is defined as significant differences found between the groups or from the 3-month to 6-month outcomes. Multiple logistic regression and univariable analysis showed that the significant outcome predictors at 6-month follow-up was the injection accuracy. Limitations: Limitations include the retrospective nature of the study, lack of evaluation of longterm effects , most of the injections were performed in patients with a BMI of less than 30 kg/m2, and the treatment procedures were conducted by the same physician. Conclusion: US-guided AC joint IA injection for the treatment of symptomatic AC joint OA resulted in better pain and functional status improvement than palpation-guided IA injection at the 6-month follow-up. Key Words: Ultrasound, injection, acromioclavicular joint, steroid

Meralgia paraesthetica: Ultrasound-guided injection at multiple levels with 12-month follow-up.

To evaluate the efficacy of ultrasound (US)-guided injections around the lateral femoral cutaneous nerve (LFCN) at different levels in meralgia paraesthetica (MP) patients. The study was approved by the university ethics committee and informed oral and written consent were obtained from all patients. Between June 2008 and August 2013, 20 patients with symptoms of MP, including nine men (mean age, 61.33 years) and 11 women (mean age 61.18 years), were treated with US-guided injection of steroids along the LFCN at three different levels in a mean of 2.25 sessions. A visual analogue scale (VAS) was used to measure symptoms before, immediately after and 12 months after treatment. Complete resolution of symptoms was documented in 15/20 patients (mean VAS decreased from 82 to 0), and partial resolution in the remaining five (mean VAS decreased from 92 to 42), which was confirmed at 12-month follow-up. By using the different levels of injection approach overall significantly better symptom relief was obtained (p < 0.05). The outcome of US-guided injection along the LFCN can be further improved by injections at different levels (p < 0.05), which was confirmed at 12-month long-term follow-up. Meralgia paraesthetica is an entrapment neuropathy of the lateral femoral cutaneous nerve. Ultrasound proved effective in diagnosis and in guiding injection therapy. Injection at the anterior superior iliac spine has been used previously. Multiple injections along the nerve course were used in this study. Long-term follow-up (12 months) confirmed the results.

Effects of Ultrasound-guided intra-articular ketorolac injection with capsular distension

Frozen shoulder is a painful condition with gradual onset and loss of range of motion in the glenohumeral joint. To investigate the efficacy of ultrasound(US)-guided intra-articular (IA) ketorolac injection with capsular distension compared with steroid injection alone in patients with frozen shoulder by assessing pain relief, functional improvements, and range of motion at 1,3 and 6 months after the last injections. Between January 2009 and December 2012, 121 patient were treated with US-guided IA steroid injection or IA ketorolac injection with capsular distension for frozen shoulder. Patients (n= 57) of US-guided IA steroid injection group were administered with a mixture of 0.5% lidocaine (4 ml) plus triamcinolone (40 mg/ml; 1 ml) and patients (n= 64) of US-guided IA ketorolac injection with capsular distension group were administered by using 0.5% lidocaine (19 mL) plus ketorolac (30 mg/ml; 1 mL) for capsular distension. Outcome measurement was assessed by Shoulder Pain and Disability Index (SPADI), Verbal Numeric pain Scale (VNS) and passive range of motion (ROM) before injections and at 1, 3 and 6 months after the last injections. We regarded the outcomes as a success if patients obtained significant pain relief (as measured by > 50% improvement in the VNS score and 20 point improvement in the SPASI) at 1, 3 and 6 months after the last injections. SPADI, VNS and passive ROM were improved 1, 3 and 6 months after the last injections in both groups. The statistical differences were not observed in SPADI, VNS between groups (p< 0.05). Successful treatment rate were not significantly different between the groups as well as in 1, 3 and 6 month outcomes. However, greater improvement was found in a matter of range of motion in patients receiving IA ketorolac injection with capsular distension than participants receiving US-guided IA steroid injection alone. Significant differences in improvement at 3 and 6 months were observed for shoulder passive abduction and external rotation (p< 0.05). IA ketorolac injection with capsular distension was shown to be a treatment method as effective as the steroid injection alone in pain relief and functional improvement in patient with frozen shoulder and more improvement in passive abduction and external rotation than steroid injection alone at 3 and 6 months.

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.

Feasibility of Ultrasound-Guided Sacroiliac Joint Injections in Children Presenting with Sacroiliitis.

To evaluate the feasibility and effectiveness of US-guided sacroiliac joint injection in the treatment of sacroiliitis in children. This study was approved by the institutional review board and informed oral and written consent was obtained from the patients and their parents. In 13 patients (7 females and 6 males), 9 - 16 years (mean +/- std 11.39 +/-1.98), 18 sacroiliac joint (SI joint) injections were performed under US guidance. All patients suffered from severe sacroiliitis. US scanning was performed using a linear-array transducer operating at 5 - 18 MHz. Rating of the patients pain using a 0 - 10 dolorimetry scale on a visual analog score (VAS) was recorded before, immediately after and 3 months after injection to monitor severity and therapeutic response. Injection could be performed in all patients without complication and showed good response immediately and 3 months after the injection with a decrease of the VAS (from mean +/- std 9.44 +/- 1.097 to 3.89 +/- 3.82, p < 0.001 and to 0.56 +/- 1.097, p < 0.05, respectively). US-guided SI joint injection was feasible in all children, relatively quick and easy to perform and appeared effective in the treatment of children with sacroiliitis.

Ultrasound-guided joint injections for MR arthrography in pediatric patients: how we do it.

In children, MR arthrography is typically performed using fluoroscopic guidance. This article explores the role of US-guided joint injections as an alternative for MR arthrography in children, discussing its advantages and disadvantages compared to standard methods. We describe techniques for performing US-guided injection of the shoulder, elbow, hip, knee, ankle and posterior subtalar joints, highlighting pertinent anatomy, routes of access and unique considerations for this modality in children. Written descriptions, images and links to video clips are used to illustrate proper arthrographic technique. We conclude that US provides effective guidance for intra-articular injection prior to MR arthrography, with the advantages of improved visualization of internal structures, reduced radiation exposure, convenience of performing the procedure portably and ease of performance. Although this paper does not address therapeutic steroid injections, these techniques could easily be translated for such purposes. We propose US guidance as a viable alternative to fluoroscopic technique for arthrography in children.

2090419 Localizing Maximal Distention in the Subdeltoid Bursa by Point-Of-Care Ultrasound Alters The Ultrasound-Guided Injection Approach

Palpation-guided corticosteroid (CS) injections are often provided from a posterior approach, aiming at the subacromial aspect of the subdeltoid bursa with varying accuracy and treatment response. Ultrasound (US) can visualize bursal fluid, thickening, tendinopathy, and tendon tears. US-guided injections are known to be accurate. Our OBJECTIVES: was to evaluate how point-of-care US affects the US-guided injection approach for treatment of shoulder pain. We retrospectively reviewed clinical and US characteristics of 67 patients with shoulder pain/impingement syndrome who received a total of 96 US-guided CS injections in an academic rheumatology US clinic. Images were obtained and interpreted by 1 expert MUS-trained rheumatologist. All images were reviewed by a 2nd US-trained physiatrist. Patients were mostly female (64.2%) with a mean age of 63.5 and BMI of 29.1. Twenty-six patients (38.8%) received prior palpation-guided injections with more than half of these patients (61.5%) reporting little to no benefit. US-guided injection approach was determined by localizing the maximal area of fluid distention or thickening of the subdeltoid bursa visualized by US, corresponding with clinical tenderness. US-guided injections were provided in the typical subacromial target, laterally over the supraspinatus tendon in 41.7% of injections; however, 58.3% of injections were targeted anterior to the acromion: anterolaterally over the subscapularis tendon (35.4%), anterolaterally over the supraspinatus tendon (20.8%) and anteriorly over the biceps tendon (2.1%). The majority of all US-guided injections (96.8%) provided improvement to complete relief immediately post-injection. Point-of-care US identified maximal distention of the subdeltoid bursa to be more commonly located anterior to the acromion rather than directly subacromial. This finding may be a reason for failed palpation-guided injections. US-guided injection approach was altered by targeting a specific location with clinical correlation. This method has the potential to improve clinical outcomes. Future prospective studies are needed.

Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis

The subtalar joint is commonly affected in children with juvenile idiopathic arthritis and is challenging to treat percutaneously. To describe the technique for treating the subtalar joint with US-guided corticosteroid injections in children and young adults with juvenile idiopathic arthritis and to evaluate the safety of the treatment. We retrospectively analyzed 122 patients (age 15months-29years) with juvenile idiopathic arthritis who were referred by a pediatric rheumatologist for corticosteroid injection therapy for symptoms related to the hindfoot or ankle. In these patients the diseased subtalar joint was targeted for therapy, often in conjunction with adjacent affected joints or tendon sheaths of the ankle. We used a protocol based on age, weight and joint for triamcinolone hexacetonide or triamcinolone acetonide dose prescription. We describe the technique for successful treatment of the subtalar joint. A total of 241 subtalar joint corticosteroid injections were performed under US guidance, including 68 repeat injections for recurrent symptoms in 26 of the 122 children and young adults. The average time interval between repeat injections was 24.8months (range 2.2-130.7months, median 14.2months). Subcutaneous tissue atrophy and skin hypopigmentation were the primary complications observed. These complications occurred in 3.9% of the injections. With appropriate training and practice, the subtalar joint can be reliably and safely targeted with US-guided corticosteroid injection to treat symptoms related to juvenile idiopathic arthritis.

DEVELOPING A TECHNIQUE FOR ULTRASOUND‐GUIDED INJECTION OF THE ADULT CANINE HIP

An accurate method for guiding injections into the canine hip would facilitate diagnostic localization of lameness and targeted treatments. Ultrasound-guided hip injections are commonly used in humans and large animals. Aims of this prospective study were to describe ultrasound (US) anatomy of the adult canine hip and determine the feasibility and accuracy of intra-articular placement of injectate using US-guidance. Seven adult dogs were used to describe US anatomy, five dog cadavers were used to assess the feasibility of the injection technique and 11 dog cadavers were used to assess accuracy of injections. For the accuracy test, 22 joints were injected with iodinated contrast medium by three operators with different experience. With dogs in lateral recumbency, the hyperechoic femoral head surface was identified by following the femoral neck from the greater trochanter or the acetabular rim was localized by following caudally the ilium from the iliac wing. An anechoic gap between the femoral head and acetabular surface represented the joint. The capsule was visible as a triangular echoic structure and the femoral head articular cartilage appeared as an anechoic band. The needle was inserted axial to the greater trochanter and directed in a dorsolateral-ventromedial direction toward the joint space and then pushed through the capsule. Based on postinjection radiography, accuracy was 81.8% at first attempt and 100% at second attempt. This study indicated that US-guided injection is a feasible and accurate technique for injecting the adult canine hip. Future studies in live dogs are needed to assess safety and efficacy.

The molecular systemic and local effects of intratendinous injection of Platelet Rich Plasma in tendinosis: preliminary results on a rat model with ELISA method

the aim of our study was thus to quantify the effect of Platelet Rich Plasma (PRP) injection on systemic and local growth factors and to identify molecular markers in a rat model of patellar and Achilles tendinosis treated with PRP. twenty two rats were used for the study. Two healthy rats were used as control (T-). We induced tendinosis (T+) in 20 rats (80 tendons by injecting under ultrasonography (US) guidance Collagenase 1® (day 0 = D0, patellar=40 and Achilles=40). At D3, these 20 rats with tendinosis were separated in treatment by either PRP (PRPT+, n=28), physiological serum (PST+, n=28, control) US-guided intratendinous injection, or without no PRP or PS (T+, n=24, control of natural evolution of tendinopathy). Follow-up at D7, D13, D18 and D25 using serum sample and local tendon removal with ELISA technics and comparison between the 3 groups were performed. during biological follow up, comparison of all serum samples of PRPT+, PST+ and T+ groups showed no significant modification of their biological markers at D7, D13, D18 and D25 (p>0.22). Comparison of immunological sample tendon markers of PRPT+, PST+ and T+ groups also showed no significant modification of markers at D7, D13, D18 and D25 (p>0.16) considering each biological marker and also all subgroups confounded. our study strongly suggests that a single intratendinous US-guided injection of PRP in Achilles and patellar T+ doesn't increase biological markers such as growth factors compared to a control group in mid-term and long-term follow-up.

Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study.

ObjectiveTo investigate the feasibility of ultrasound (US)-guided steroid injection by in-plane approach for cubital tunnel syndrome (CuTS), based on symptomatic, morphologic and electrophysiological outcomes.MethodsA total of 10 patients, who were clinically diagnosed as CuTS and confirmed by an electrodiagnostic study, participated in this study. US-guided injection into the cubital tunnel was performed with 40 mg triamcinolone and 2 mL of 1% lidocaine. Outcomes of the injections were evaluated at pre-injection, 1st week and 4th week after injection. Visual analog scale, self-administered questionnaire of the ulnar neuropathy at the elbow (SQUNE), and McGowan classification were used for clinical evaluation. Cross-sectional area of the ulnar nerve by US and the electrophysiological severity scale through a nerve conduction study were utilized in the evaluation of morphologic and electrophysiological changes. The cross-sectional area of the ulnar nerve was measured at 3 points of condylar, proximal, and distal level of the cubital tunnel.ResultsNo side effects were reported during the study period. The visual analog scale and cross-sectional area showed a significant decrease at 1st week and 4th week, as compared to baseline (p<0.05). The electrophysiological severity scale was significantly decreased at the 4th week, as compared with baseline and 1st week (p<0.05). Among the quantitative components of the scale, there were statistically significant improvements with respect to the conduction velocity and block.ConclusionThe new approach of US-guided injection may be a safe tool for the treatment of CuTS. Symptomatic and morphologic recoveries preceded the electrophysiological improvement.

Spread patterns and effectiveness for surgery after ultrasound-guided rectus sheath block in adult day-case patients scheduled for umbilical hernia repair.

Background and Aims:We conducted a prospective study to examine the local anesthetic (LA) spread and the effectiveness for surgical anesthesia of ultrasound (US)-guided rectus sheath block (RSB) in adult patients undergoing umbilical hernia repair.Material and Methods:Thirty patients received at T-10 level a bilateral US-guided injection of 20 mL levobupivacaine 0.375% + epinephrine 5 μg/mL behind the rectus muscle to detach it from its sheath. Anesthetic spread into the rectus sheath was evaluated ultrasonographically at T-9 and T-11 levels and scored from 0 to 4. The RSB was defined effective for surgical anesthesia if it was able to guarantee an anesthetic level sufficient for surgery without any mepivacaine supplementation.Results:Overall, the block was effective for surgical anesthesia in 53.3% of patients (95% confidence interval, ±17.8). In the remaining patients, anesthesia supplementation was needed at cutaneous incision, whereas manipulation of the muscle and fascial planes was painless. No patients required general anesthesia. LA spreads as advocated (to T-9 and to T-11 bilaterally = spread score 4) in 8/30 patients (26.6%); in these cases, the block was 75% effective for surgery. The anesthetic spread was most negatively influenced by increased body mass index. Postoperative analgesia was excellent in 97% of patients.Conclusion:Use of RSB as an anesthetic management of umbilical herniorrhaphy is recommended only with anesthetic supplementation at the incision site.