Intra-articular injection techniques of the buffalo (Bubalus bubalis) hindlimb digit using anatomical and contrast arthrography-guided landmarks.

This study was designed to evaluate and compare the optimal sites for intra-articular (IA) injection into the digits of buffalo by discrimination of the injection criteria. Forty-eight cadaveric hind digits of adult buffalos and nine live ones were assigned for three trial investigations. In the first division, eighteen sound cadaveric limbs were used to describe the anatomical features of the hind digit. In the second division, thirty cadaveric limbs (ten for each approach) were injected with an equal volume of iopamidol through relevant joint pouches to compare the dorsal, lateral and plantar IA approaches for each joint. The former technique was applied to nine live, healthy adult buffaloes to evaluate the accuracy of IA injection of the hind digit in vivo. Injection criteria were assessed, scored and statistically compared among the three approaches. The summation of injection criteria scores showed a significant increase (P < 0.05) in the dorsal and lateral approaches for IA injection of the fetlock, pastern and coffin joints in the buffalo digit compared to the plantar one. However, median and range of injection criteria scores between the dorsal and lateral approaches were slightly less significant. In conclusion, the present study established a reference for IA injection of the buffalo digit that could aid the diagnosis and treatment of digit-related lameness.

Comparison of Arthroscopic Lavage and Needle Lavage Techniques, and Lavage Volume on the Recovery of Colored Microspheres From the Tarsocrural Joints of Cadaver Horses.

OBJECTIVE: To quantify recovery of colored microspheres from normal cadaver tarsocrural joints using arthroscopic or needle lavage with 1-5 L of fluid. STUDY DESIGN: Ex vivo experimental study. ANIMALS: Adult Quarter Horse cadavers (n = 8). METHODS: After euthanasia, 1.5 × 10(6) colored microspheres were injected into each tarsocrural joint. Each joint was randomly assigned to receive lavage (5 L 0.9% NaCl) with an arthroscope (dorsomedial arthroscope and dorsolateral egress cannula) or three 14 g needles (dorsomedial ingress, dorsolateral, and plantarolateral egress). Egress fluid from each liter was collected separately over time and the number of microspheres present in each recovered liter determined by spectrophotometry. RESULTS: A significant interaction was present between treatment group and liter of fluid (P < .01). The number of microspheres recovered in the first liter of lavage fluid was significantly higher in the needle lavage group than in the arthroscopic lavage group (P < .01). For both groups, the number of microspheres recovered in the first liter of lavage fluid represented a majority of the total microspheres collected and was significantly different from each subsequent liter collected (P < .01). The number of microspheres recovered did not differ between liters 2, 3, 4, and 5 within or between treatment groups. CONCLUSION: In this model, tarsocrural lavage with three 14 g needles was more effective at removing colored microspheres from the joint than arthroscopic lavage, suggesting that the number or placement of portals present may be more important than portal size and flow rate. No difference in microsphere recovery was seen with lavage volumes >1 L.

Comparative effectiveness of infraclavicular and supraclavicular perineural catheters for ultrasound-guided through-the-catheter bolus anesthesia.

OBJECTIVES: Using a through-the-needle local anesthetic bolus technique, ultrasound-guided infraclavicular perineural catheters have been shown to provide greater analgesia compared to supraclavicular catheters. A through-the-catheter bolus technique, which arguably "tests" the anesthetic efficacy of the catheter before initiating an infusion, has been validated for infraclavicular catheters but not supraclavicular catheters. This study investigated the through-the-catheter bolus technique for supraclavicular catheters and tested the hypothesis that infraclavicular catheters provide faster onset of brachial plexus anesthesia. METHODS: Preoperatively, patients were randomly assigned to receive either a supraclavicular or an infraclavicular catheter using an ultrasound-guided nonstimulating catheter insertion technique with a mepivacaine bolus via the catheter and ropivacaine perineural infusion initiated postoperatively. The primary outcome was time to achieve complete sensory anesthesia in the ulnar and median nerve distributions. Secondary outcomes included procedural time, procedure-related pain and complications, and postoperative pain, opioid consumption, sleep disturbances, and motor weakness. RESULTS: Fifty patients were enrolled in the study; all but 2 perineural catheters were successfully placed per protocol. Twenty-one of 24 (88%) and 24 of 24 (100%) patients in the supraclavicular and infraclavicular groups, respectively, achieved complete sensory anesthesia by 30 minutes (P= .088). There was no difference in the time to achieve complete sensory anesthesia. Supraclavicular patients reported more sleep disturbances postoperatively, but there were no statistically significant differences in other outcomes. CONCLUSIONS: Both supraclavicular and infraclavicular perineural catheters using a through-the-catheter bolus technique provide effective brachial plexus anesthesia.

[Musculoskeletal puncture, injection and infiltration: swiss rheumatologists' point of view]. / Muskuloskelettale Punktion, Injektion und Infiltration: Standpunkt von Schweizer Rheumatologen.

Arthrocentesis, injection and infiltration of joints and soft tissues belong to the basic procedures in rheumatology. The indications and the practical performance are based on experience and tradition. Nowadays, a crucial reappraisal and adaption of indications and technical aspects appear important in the light of new evidence and technical developments. The main indications for puncture remain the search of an infectious arthritis and reduction of intra-articular pressure due to effusion. Good indications for the injection of glucocorticoids are inflammation in sterile joints and activated osteoarthritis. The local infiltration with corticosteroids in mechanically induced enthesopathies at the lateral epicondyle of the humerus or at the plantar fascia have to be questioned in the light of recent publications which show that this common practice is associated with a poorer outcome than without injection.

[Ultrasound-guided joint injections in patients with rheumatic diseases]. / Sonographisch geführte Gelenkpunktionen in der Rheumatologie.

Joint and soft tissue injections are routinely performed in daily rheumatology practice to establish the diagnosis or as part of the treatment in patients suffering from rheumatic diseases. Consequently, joint injections have been included in the rheumatology further training curriculum. Despite numerous studies demonstrating a poor accuracy and outcome of joint injections guided only by clinical examination, most of the injection procedures are still performed in a "blind" fashion based on clinical judgment. Ultrasound has evolved as an established imaging method in rheumatology within the past decade and is considered the preferred imaging modality for joint interventions due to its availability and lack of radiation exposure. In this article the indications and important aspects of the practical management of ultrasound-guided injections performed in daily rheumatology practice are summarized.

Helpful tips for performing musculoskeletal injections.

Injections are valuable procedures for managing musculoskeletal conditions commonly encountered by family physicians. Corticosteroid injections into articular, periarticular, or soft tissue structures relieve pain, reduce inflammation, and improve mobility. Injections can provide diagnostic information and are commonly used for postoperative pain control. Local anesthetics may be injected with corticosteroids to provide additional, rapid pain relief. Steroid injection is the preferred and definitive treatment for de Quervain tenosynovitis and trochanteric bursitis. Steroid injections can also be helpful in controlling pain during physical rehabilitation from rotator cuff syndrome and lateral epicondylitis. Intra-articular steroid injection provides pain relief in rheumatoid arthritis and osteoarthritis. There is little systematic evidence to guide medication selection for therapeutic injections. The medication used and the frequency of injection should be guided by the goal of the injection (i.e., diagnostic or therapeutic), the underlying musculoskeletal diagnosis, and clinical experience. Complications from steroid injections are rare, but physicians should understand the potential risks and counsel patients appropriately. Patients with diabetes who receive periarticular or soft tissue steroid injections should closely monitor their blood glucose for two weeks following injection.

Needle Length Requirement for Glenohumeral Joint Injection Using the Neviaser Approach.

Intra-articular glenohumeral joint injections are commonly performed in the clinical setting for diagnostic and therapeutic purposes. Multiple approaches are described, including the anterior and posterior approaches and the less studied superomedial (Neviaser) approach. The purpose of this study was to determine the length of needle required to enter the shoulder joint via the Neviaser approach by radiography and magnetic resonance imaging (MRI) measurements. Additionally, the authors sought to identify any correlation between needle length and body mass index (BMI). They performed a retrospective review of 101 consecutive patients evaluated by one faculty member at their institution. Inclusion criteria were age older than 50 years, no previous shoulder surgery, no history of acromioclavicular joint injury, and having a true anteroposterior radiograph and MRI within 1 year of each other. Using a digital imaging system, the Neviaser approach needle path was drawn for both images, and the lengths were measured. Correlation coefficients for needle length and BMI were calculated. The images of 58 (57.4%) male patients and 43 (42.6%) female patients were evaluated (average BMI, 31.2 kg/m2). The average needle length measurement was 4.27 cm on radiograph and 3.9 cm on MRI. Correlation coefficients were r=0.36 (P=.0002) using radiographs and r=0.53 (P<.0001) using MRIs. When using the Neviaser approach, there is a moderate positive correlation between BMI and the measured distance between skin and the glenohumeral joint when assessed on MRI, and a weak positive correlation on radiographs. The authors conclude that an injection needle of 2 inches or greater is required to reliably access the shoulder joint, and this length may increase with increasing BMI. [Orthopedics. 2020;43(4):e215-e218.].

Comparison of needle position proximity to the median nerve in 2 carpal tunnel injection methods: a cadaveric study.

PURPOSE: Steroid injections are commonly performed by hand surgeons for relief of symptoms associated with carpal tunnel syndrome. The purpose of this study is to examine the relationship of the needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch, using 2 injection techniques. METHODS: Simulated carpal tunnel injections were performed on 15 cadaveric arms using 2 methods. The first injection used a widely accepted approach in which the needle is inserted at the wrist crease, just ulnar to the palmaris longus, and directed at a 30 degrees angle to the horizontal. In the second method, the needle is positioned just ulnar to the palpable ulnar border of flexor carpi radialis and angled 30 degrees to the horizontal. Specimens were dissected using an open carpal tunnel release. Calipers measured the distance from each needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch. RESULTS: Using the first injection method, the needle pierced the median nerve in 4 specimens, and its mean distance from the nerve measured 1.34 mm +/- 1.83 mm. With the second injection method, the median nerve was pierced in 1 specimen, and the needle averaged a distance of 4.79 mm +/- 3.96 mm from the nerve. In the first approach, the needle averaged 9.47 mm +/- 4.11 mm from the palmar cutaneous branch, compared to 1.74 mm +/- 1.59 mm with the second technique. CONCLUSIONS: Physicians must exercise caution when performing carpal tunnel injections to avoid intraneural injection. The needle was a statistically significant shorter distance to the median nerve with the traditional injection method; however, the alterative method risks injury to the palmar cutaneous branch of the median nerve.

An orthopedic injection training instrument using flow impedance to indicate needle tip locations.

OBJECTIVE: The project aimed to design an instrument that can provide visual, quantitative feedback to medical students and help them develop intuitive, tactile-based injection skills. METHODS: The instrument uses force and displacement sensors to find flow impedance, the ratio of the pressure applied to fluid in the syringe to the fluid flow rate, of different tissues. A software program utilizes these flow impedances to identify needle tip location-either joint or tendon. Injection experiments with pork feet were completed to collect flow impedance data when the needle tip was located in joint or tendon. Injections used deionized water and aqueous pullulan solutions to study the instrument's effectiveness when medical therapies of different viscosities are injected. For each solution, at least 13 injections were conducted. The mean and standard deviation of the flow impedances from injections with each solution were obtained. RESULTS: In all experimental cases, the flow impedance demonstrated by the tendon is a number of times higher than that of the joint cavity: the impedance ratios (tendon to joint cavity) for water, 3 w/w% pullulan, and 15 w/w% pullulan are 74, 62, and 6, respectively. CONCLUSIONS: The results confirmed the concept of using flow impedance to index the needle tip location-whether the tip is positioned in joint or tendon. This instrument's user interface can serve as a training aid for medical students and infrequent operators.

Syringe size: does it matter in physician-performed procedures?

PURPOSE: We hypothesized that the size of syringe influenced needle control in physician-performed procedures. MATERIALS AND METHODS: Operators were tested for their ability to control a 1-, 3-, 5-, 10-, and 20-mL syringe and equivalent sizes of the new safety device, the reciprocating procedure device (RPD), using the quantitative needle-based displacement method. Three hundred twenty clinical syringe procedures were then randomized to either a 3- or 10-mL conventional syringe or to a 3- or 10-mL RPD. Patient pain was measured with the Visual Analog Pain Scale (VAPS). RESULTS: Increasing syringe size was associated with the undesirable characteristic of unintended forward penetration (loss of control of the needle in the forward direction) (r(2) = 0.97, slope = 2.14, 95% CI: 1.54-2.76, P < 0.002), and unintended retraction (loss of control of the needle in the reverse direction) (r(2) = 0.97, slope 2.15, 95% CI: 1.54-2.76, P < 0.002). In addition, 2-handed operation of a syringe resulted in greater control than 1-handed operation of a syringe (P < 0.001). When 1-handed operation was required, the RPD control syringe reduced unintended penetration by 52.3% (P >or= 0.001), unintended retraction by 56.8% (P >or= 0.001), and patient pain by 54.7% (P >or= 0.001) at each device size. CONCLUSIONS: For greater safety and control when operating the conventional syringe, smaller syringe sizes and 2 hands instead of 1 hand should be used whenever possible. If 1-handed operation of a syringe is necessary, a safety technology like the RPD control syringe should be used.

Distances to the subacromial bursa from 3 different injection sites as measured arthroscopically.

PURPOSE: The purpose of this study was to assess the distance for a standard needle to reach the subacromial bursa through 3 commonly used approaches. METHODS: Thirty patients without associated rotator cuff tears underwent arthroscopic evaluation of the shoulder. The bursa was entered without shaving or altering of the bursa. By use of standard arthroscopic portals, a spinal needle was inserted from an anterior, lateral, and posterior position and measured to define the distance to the subacromial bursa from the skin. RESULTS: The mean distance with anterior needle placement was 2.9 +/- 0.6 cm. The mean distance with lateral needle placement was 2.9 +/- 0.7 cm. The mean distance with posterior needle placement was 5.2 +/- 1.1 cm. The mean body mass index for the group of patients was 27.5. The minimum was 18.7, and the maximum was 42.8. CONCLUSIONS: The distance to the subacromial bursa from the anterior and lateral approaches appears to be consistent and within reach of a standard 22- or 25-gauge needle. The distance to the subacromial bursa from a posterior approach appears to be almost double that of the anterior and lateral approaches and may not be reachable by standard 22- and 25-gauge needles in all patients. There appears to be no correlation between distances to the subacromial bursa from the anterior, lateral, or posterior approaches and the patient's body mass index. CLINICAL RELEVANCE: Given the relative distances measured to the subacromial bursa from the anterior, lateral, and posterior positions, clinicians may choose a longer needle to improve the accuracy of placement when approaching the subacromial bursa from a posterior position. Use of a standard-length needle will provide reasonable accuracy from the anterior and lateral positions.

Ultrasound-guided periarticular injections of the sacroiliac region in horses: a cadaveric study.

REASON FOR PERFORMING STUDY: The traditional techniques for injection of the sacroiliac (SI) region are based on external landmarks. Because of the depth of the SI joint and pathological modifications, SI injections are sometimes challenging in horses. HYPOTHESIS: An ultrasound-guided techniques would allow placement of the needle without depending on external landmarks. METHODS: Fourteen pelvic specimens were isolated from mature horses. A 20 cm bent spinal needle was positioned with ultrasonographic guidance under both iliac wings aiming for SI joints using 5 approaches: cranial, craniomedial, medial and 2 caudal approaches. The length of needle inserted was recorded and 2 ml of latex injected. The distance from latex to the closest sacral articular margin, the contact between latex and the SI interosseous ligament or the contact with the neurovascular structures emerging from the greater sciatic foramen were recorded at the time of dissection. RESULTS: Latex was identified under the iliac wing in all injections but one. The distance from the latex to the closest sacral articular margin was significantly shorter (P = 0.02) for the 2 caudal approaches compared to the cranial, craniomedial and medial approaches. Contact between latex and the SI interosseous ligament was significantly more frequent (P = 0.01) with the cranial, craniomedial and medial approaches (38/73) compared to the caudal approaches (1/24). Contact between latex and the neurovascular structures was significantly less frequent (P = 0.005) for the cranial and craniomedial approaches (0/47) compared to the medial and caudal approaches (8/60). Four erratic injections were encountered. CONCLUSIONS: Ultrasonographic guidance allowed the needle to engage under the iliac wing without being dependent on external landmarks. The caudal approaches allowed deposition of liquid extremely close to the SI joint although retroperitoneal injections occurred. CLINICAL RELEVANCE: Each approach has advantages/drawbacks that could be favoured for selected purposes, but additional work is required to evaluate them on clinical cases.

Sacroiliac Joint Intraarticular Injection in True Anteroposterior View: Description of a New C-Arm Guided Method.

BACKGROUND: The anatomic characteristics of the sacroiliac joint (SIJ) make it difficult to achieve intraarticular injection without radiologic guidance. The classic C-arm guided SIJ intervention technique is difficult. Here we describe a new and simple method for SIJ intraarticular intervention. OBJECTIVE: This study aims to introduce a new, simple approach for SIJ intraarticular intervention. STUDY DESIGN: An observational case series study. SETTING: The study was conducted at an academic medical center in a major metropolitan city. METHODS: This method of intervention was performed on 57 patients (a total of 73 joints) who were selected for diagnostic and therapeutic SIJ intervention. The procedure was done in anteroposterior (AP) view, without any C-arm angulation. The accuracy of the intraarticular injection was confirmed by using intraarticular contrast material. A numerical rating scale (NRS) score was recorded for each joint before and after the procedure; the number of x-ray exposures and number of attempts were recorded for each procedure as well. RESULTS: Successful intraarticular contrast spread was obtained in all SIJs. The number of x-ray exposures was about 9 ± 3, and there was not a remarkable difference between cases according to gender of the patient (P = 0.1) or side of the joint (P = 0.2). In 5 cases, the first needle placement was not correct; there were no differences between gender (P = 0.4) and side of the joint (P = 0.4) regarding the first successful attempt. The NRS pain scores decreased in all of the patients more than 50% after the procedure; the pain scores were similar to the results of classic methods of intraarticular interventions with successful contrast spread, and there were no remarkable differences considering gender (P = 0.5) or side of the joint (P = 0.8). LIMITATIONS: This is a very small, nonrandomized, and controlled study; further blinded clinical trials are needed to clarify the probable advantages of this method compared with conventional ones. CONCLUSION: This observational study introduces a new and simple approach for SIJ intraarticular intervention, with a high success rate. KEY WORDS: Low back pain, sacroiliac joint, C-arm, new technique, intraarticular, injection.

Development of a computer-assisted high-pressure Injection device for vertebroplasty.

A novel computer-assisted injection device for the delivery of highly viscous bone cements in vertebroplasty is presented. It addresses the shortcomings of manual injection systems ranging from low-pressure and poor level of control to device failure. The presented instrument is capable of generating a maximum pressure of 5000 kPa in traditional 6-ml syringes and provides an advanced control interface for precise cement delivery from outside radiation fields emitted by intraoperative imaging systems. The integrated real-time monitoring of injection parameters, such as flow-rate, volume, pressure, and viscosity, simplifies consistent documentation of interventions and establishes a basis for the identification of safe injection protocols on the longer term. Control algorithms prevent device failure due to overloading and provide means to immediately stop cement flow to avoid leakage into adjacent tissues.

[On the main stages of the history of intra-articular therapy]. / Sulla storia delle terapie intra-articolari. Le tappe principali.

In this review the main stages in the history of intra-articular therapy of the rheumatic diseases are summarized. The first approach to such a local treatment has been likely performed in 1792 by the French physician Jean Gay, who injected in a swelling knee the "eau du Goulard" (Goulard's water), namely a mixture based on lead compounds. In the XIX century iodine derivatives have been mainly applied as an intra-articular treatment. In the XX century, before the wide use of intra-articular corticosteroids, chiefly due to the Joseph Lee Hollander's experiences, a variety of drugs has been employed, including cytostatics and sclerosing substances. A further important stage has been synoviorthesis, by using specific radionuclides, that would actually represent an anti-synovial treatment. In the last years a spread use of intra-articular hyaluronic acid, particularly in osteoarthritis, has been recorded, with the aim to warrant articular viscosupplementation. Future of intra-articular treatment should be represented by the biological drugs, i.e., anti-TNF, but it is still untimely to define the exact role of such a local treatment of arthritis.

In vivo feasibility of real-time MR-US fusion imaging lumbar facet joint injections.

OBJECTIVES: Traditionally, facet joint injections (FJI) are performed under fluoroscopic or computed tomography (CT) guidance, mainly due to the deep anatomical location and the presence of bony landmarks. Fusion imaging technology, which couples the ultrasound scan with the corresponding CT or magnetic resonance (MR) image obtained from the diagnostic examination and reformatted in real time according to the ultrasound scanning plane, allows to combine the panoramic view and the elevated anatomical detail of MR or CT with the ease of use of ultrasound without patient exposure to ionizing radiation. METHODS: Thirty eight patients (24 females; mean age ± SD: 64 ± 9 years) received MR fusion-assisted ultrasound-guided FJI of 1 ml of a mixture of local anaesthetic and corticosteroid using a ultrasound machine (Logiq E9, GE Healthcare) equipped with a GPS-enhanced fusion imaging technology which couples real-time B-mode images with those of the previous recent diagnostic MR examination. Low-dose CT needle positioning confirmation was performed in the first 28 patients. Patients' pain was recorded using a visual analogue scale (VAS), at baseline and at 2, 4 and 8 weeks. RESULTS: All fusion imaging-guided injections were performed successfully. Out of 112, 96 FJI had optimal intra-articular needle positioning (accuracy: 85.7%). Patients VAS significantly decreases after the procedure with no differences among who received CT needle positioning control and who did not receive it. No major complications were observed. CONCLUSIONS: Ultrasound needle guidance with MR fusion assistance allows for safe and effective injection of degenerative facet joint disease.

The efficacy and safety of epidural filter catheters when used for post-operative intra-articular anaesthesia.

UNLABELLED: There are concerns about the risk of iatrogenic infection when employing local anaesthetic techniques with post-operative intra-articular infusions in total knee arthroplasty. This study aimed to determine the efficacy of intact epidural filters in preventing transit of bacteria and to develop a technique of administration which would prevent membrane rupture. Filter efficacy was assessed using a standardised test suspension of Pseudomonas aeruginosa. Twenty millilitres of suspension was injected through isolated epidural filters (n=10) or filters with 40cm of catheter tubing attached (n=30). For each filter, injections were carried out at 0, 8 and 24h. Filtrates were collected, incubated, sub-cultured onto Columbia horse blood agar and examined for bacterial growth. Three delivery techniques were tested: manually controlled syringe with 5ml of water at 20ml/min, forced administration syringe with 5ml of water at >240ml/min and an automated syringe driver delivering 40ml of water at 6.7ml/min. For the two techniques using syringes, three syringe sizes, 5ml, 10ml and 20ml, were tested. Each test condition was carried out on 10 filters (total n=70). Filters were examined for rupture. Intact epidural filters prevented bacterial transit in all cases. Manual controlled and automated syringe driver administration generated no filter ruptures. Manual forced administration generated 93% filter rupture. Ruptures occurred at peak pressures of approximately 620kPa. Epidural filters can be used to prevent bacterial transit. These results suggest automated devices remove the risk of filter rupture. This study is relevant to all specialties that utilise these filters during infiltration such as epidurals or other regional anaesthetic techniques. CLINICAL RELEVANCE: This study identified that filters are prone to rupture with high infusion rates and that manual techniques are particularly vulnerable. From these results, it is recommended that pumps are used to minimise risk of filter rupture.

Ultrasound-Guided Foot and Ankle Procedures.

This article reviews commonly performed injections about the foot and ankle region. Although not exhaustive in its description of available techniques, general approaches to these procedures are applicable to any injection about the foot and ankle. As much as possible, the procedures described are based on commonly used or published techniques. An in-depth knowledge of the regional anatomy and understanding of different approaches when performing ultrasonography-guided procedures allows clinicians to adapt to any clinical scenario.