Three-Month Complication Rate of Ultrasound-Guided Soft Tissue Surgical Procedures Across Six Sports Medicine Clinics.

OBJECTIVES: To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications. METHODS: A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates. RESULTS: Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified. CONCLUSION: This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics.

Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: Preliminary Clinical Results.

Ultrasound-guided carpal tunnel release was performed on 14 patients (18 wrists) using dynamic expansion of the transverse safe zone. Our patient population included able-bodied patients and those with impairments. The first 8 cases (12 wrists) underwent the procedure in an operating room, the remainder in an outpatient setting. No complications occurred, and all patients were able to immediately resume use of their hands without therapy. Improvements in the Quick Form of the Disabilities of the Arm, Shoulder, and Hand Index and Boston Carpal Tunnel Questionnaire at 3 months were comparable to results reported with mini-open and endoscopic release. Our results show that ultrasound-guided carpal tunnel release can be safely and effectively performed in an outpatient setting.

Sonographic Changes After Ultrasound-Guided Release of the Transverse Carpal Ligament: A Case Report.

Carpal tunnel syndrome is the most common entrapment neuropathy, resulting in 500,000 carpal tunnel release (CTR) surgeries and a total cost of more than 2 billion dollars annually in the United States. Although initially performed via a large (3-5 cm) palmar incision, CTR techniques have continually evolved to reduce incision size, recovery times, postoperative pain, and improve cosmesis and clinical outcomes. More recently, multiple authors have reported excellent results after ultrasound-guided carpal tunnel release (USCTR) using a variety of techniques, and one prospective randomized trial reported faster recovery after USCTR compared with traditional mini-open CTR. However, there is a paucity of data with respect to changes in the median nerve after USCTR. This case report presents the functional outcomes and pre- and postprocedure ultrasound images of a patient after USCTR with 3-month follow-up. LEVEL OF EVIDENCE: V.

Percutaneous Ultrasonic Tenotomy for Refractory Common Extensor Tendinopathy After Failed Open Surgical Release: A Report of Two Cases.

Common extensor tendinopathy (CET) is a common, painful overuse and degenerative condition of the lateral elbow, affecting an estimated 2 million patients per year. Although many cases resolve with conservative treatment, recalcitrant cases may progress to open surgical intervention. For patients who do not improve with surgical management, treatment options are extremely limited. In this article, we present 2 cases of recalcitrant surgically treated CET successfully treated with sonographically guided percutaneous ultrasonic tenotomy with 1-year follow-up. To our knowledge, this is the first publication demonstrating successful treatment of recalcitrant CET after open surgical repair, with the use of ultrasonic tenotomy. LEVEL OF EVIDENCE: V.

Ultrasound-Guided Interventional Procedures of the Wrist and Hand: Anatomy, Indications, and Techniques.

Acute and chronic wrist and hand conditions are commonly seen by neuromuscular and musculoskeletal specialists. High-frequency diagnostic ultrasonography (US) has facilitated advances in the diagnosis and interventional management of wrist and hand disorders. US provides excellent soft tissue resolution, accessibility, portability, lack of ionizing radiation, and the ability to dynamically assess disorders and precisely guide interventional procedures. This article review the relevant anatomy, indications, and interventional techniques for common disorders of the wrist and hand, including radiocarpal joint arthritis, scaphotrapeziotrapezoidal joint arthritis, trapeziometacarpal joint arthritis, phalangeal joint arthritis, first dorsal compartment tenosynovitis, ganglion cysts, and stenosing tenosynovitis.

Ultrasound-Guided Interventional Procedures About the Shoulder: Anatomy, Indications, and Techniques.

Chronic and acute shoulder pain and dysfunction are common complaints among patients. Shoulder pain may be the result of abnormality involving the rotator cuff, subacromial-subdeltoid bursa, biceps tendon, glenoid labrum, glenohumeral joint, acromioclavicular joint, sternoclavicular joint, or glenohumeral joint capsule. Ultrasound-guided (USG) procedures of the shoulder are well established for interventional management. Ultrasound provides the advantages of excellent soft tissue resolution, injection accuracy, low cost, accessibility, portability, lack of ionizing radiation, and the ability to perform real-time image-guided procedures. The purpose of this article is to review common indications and effective techniques for USG injections about the shoulder.

Percutaneous Ultrasonic Fasciotomy for Refractory Plantar Fasciopathy After Failure of a Partial Endoscopic Release Procedure.

Plantar fasciopathy is a painful, degenerative condition of the plantar fascia that affects 2 million people annually and has an estimated 10% lifetime prevalence. When both nonoperative and operative management fails, patients have limited therapeutic options. We present a case of an active 47-year-old male runner who was successfully treated with songraphically guided percutaneous ultrasonic fasciotomy after undergoing a prolonged course of nonoperative management and an endoscopic plantar fascia release procedure. Percutaneous ultrasonic fasciotomy may be considered in patients with chronic, refractory plantar fasciopathy, including those for whom a prior operative release procedure has failed.

Atypical Coxa Saltans Due to Partial Proximal Hamstring Avulsion: A Case Presentation Highlighting the Role for Dynamic Sonography.

Painful hip snapping can present as a rare sequela of proximal hamstring injury. We present a case of painful snapping of the conjoint tendon of the semitendinosus and biceps femoris over the ischial tuberosity in the setting of a partial proximal hamstring disruption. Dynamic ultrasonography identified the source of snapping and a persistent attachment of the conjoint tendon to the sacrotuberous ligament, which prevented retraction and allowed subluxation of the tendons across the ischial tuberosity. Following surgical transection of the persistent sacrotuberous ligament attachment to the conjoint tendon and tendon reattachment, the patient's symptoms resolved with full return of function.

Optimal Elbow Angle for Sonographic Visualization of the Ulnar Collateral Ligament.

OBJECTIVE: To formally examine the sonographic appearance of the elbow ulnar collateral ligament (UCL) at 30° versus 70° of elbow flexion in asymptomatic baseball pitchers. DESIGN: A prospective, cross-sectional design. SETTING: Sports medicine clinic in a tertiary academic medical center. PARTICIPANTS: Thirty asymptomatic adolescent baseball pitchers 13-18 years of age (mean 15.8 years), with at least 3 years of continuous pitching experience and no significant history of elbow pain or injury. METHODS: Static sonographic images of the bilateral UCLs were obtained at 30° and 70° of elbow flexion by a single experienced examiner. Images were anonymized and randomized into a slide set. Three clinicians with different levels of ultrasound experience reviewed the static 30° and 70° images for each elbow and chose their preferred image based on UCL conspicuity. The clinicians reviewed a re-randomized slide set 1 week later. A different study co-investigator measured UCL cross-sectional area (CSA) on all images using ultrasound machine electronic calipers. MAIN OUTCOME MEASURES: Preference for the sonographic conspicuity of the UCL at 30° versus 70° of elbow flexion, and UCL CSA at 30° versus 70° of flexion. RESULTS: Each clinician demonstrated a significant preference for UCL images obtained at 70° of flexion when compared to those obtained at 30° (80.3% overall preference for 70°, P < .001). There was no statistically significant effect of clinician experience or arm dominance on image preference. The sonographically determined CSA of the UCLs were on average 1.4 mm(2) greater at 70° than at 30° of flexion (P < .001) when combining dominant and nondominant arms. CONCLUSIONS: Static sonographic evaluation of the UCL at 70° of elbow flexion should be integrated into UCL imaging protocols. Furthermore, when performing sonographically guided procedures targeting the UCL, clinicians should consider positioning the elbow at >30° of flexion to optimize UCL conspicuity and CSA.

Sonographically guided sternoclavicular joint injection: description of technique and validation.

OBJECTIVES: The primary purpose of this investigation was to describe and validate a sonographically guided technique for injecting the sternoclavicular joint (SCJ) using a cadaveric model. METHODS: A single experienced operator (J.S.) completed 13 sonographically guided SCJ injections on 7 unembalmed cadaveric specimens (4 male and 3 female) using an out-of-plane, caudad-to-cephalad technique to place 1 mL of diluted blue latex into the joint. Within 72 hours, study coinvestigators dissected each specimen to determine the injectate location. RESULTS: All 13 injections accurately placed latex into the SCJ with a predilection for the clavicular side (accuracy, 100%; 95% confidence interval, 73%-100%). Three injections (23%) placed all latex on the clavicular side of the SCJ in the presence of a complete intra-articular disk. Dissection revealed incomplete degenerated disks in the remaining 10 joints. Seven of these injections (54%) clearly placed more than 80% of the latex on the clavicular side, whereas the remaining 3 injections (23%) showed nearly equal latex distribution between the clavicular and sternal sides. No injection resulted in neurovascular injury or extracapsular flow. CONCLUSIONS: Sonographically guided SCJ injections can be considered in the diagnosis and management of patients presenting with medial shoulder pain syndromes and, using the technique described herein, have a predilection to target the clavicular portion of the joint. In younger patients with possible complete intra-articular disks or in patients with sternal-side conditions, practitioners should consider confirming sternal-side flow after injection or attempt to specifically target the sternal side of the joint.

Intraarticular platelet-rich plasma injection in the treatment of knee osteoarthritis: review and recommendations.

Intraarticular platelet-rich plasma (PRP) injection has emerged as a promising treatment for knee osteoarthritis. Studies to date, including multiple randomized controlled trials, have shown that PRP is a safe and effective treatment option for knee osteoarthritis. Intraarticular PRP is similar in efficacy to hyaluronic acid, and seems to be more effective than hyaluronic acid in younger, active patients with low-grade osteoarthritis. Treatment benefits seem to wane after 6-9 mos. There are numerous PRP treatment variables that may be of importance, and the optimal PRP protocol remains unclear. Future investigations should control and analyze the effects of these variables in PRP treatment. High-quality randomized controlled trials are needed to optimize PRP treatment methods and better define the role of PRP in osteoarthritis management in the knee and, potentially, in other joints.