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.

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.].

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.

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.

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.

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.

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.

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.

Common injections in musculoskeletal medicine.

Musculoskeletal injections are a common procedure in primary care and sports medicine but can be intimidating for some clinicians. This article addresses current evidence for corticosteroid injections, and common injection indications and techniques, namely knee, subacromial bursa, glenohumeral joint, lateral epicondyle, de Quervain tenosynovitis, and greater trochanteric bursa injections. Preparation for injections and some evidence for ultrasound guidance are also reviewed.

Ultrasound-guided facet joint injection training using Perk Tutor.

PURPOSE: Facet syndrome is a condition that may cause 15-45 % of chronic lower back pain. It is commonly diagnosed and treated using facet joint injections. This needle technique demands high accuracy, and ultrasound (US) is a potentially useful modality to guide the needle. US-guided injections, however, require physicians to interpret 2-D sonographic images while simultaneously manipulating an US probe and needle. Therefore, US-guidance for facet joint injections needs advanced training methodologies that will equip physicians with the requisite skills. METHODS: We used Perk Tutor-an augmented reality training system for US-guided needle insertions-in a configuration for percutaneous procedures of the lumbar spine. In a pilot study of 26 pre-medical undergraduate students, we evaluated the efficacy of Perk Tutor training compared to traditional training. RESULTS: The Perk Tutor Trained group, which had access to Perk Tutor during training, had a mean success rate of 61.5 %, while the Control group, which received traditional training, had a mean success rate of 38.5 % ([Formula: see text]). No significant differences in procedure times or needle path lengths were observed between the two groups. CONCLUSIONS: The results of this pilot study suggest that Perk Tutor provides an improved training environment for US-guided facet joint injections on a synthetic model.

Eficacia y seguridad de una única inyección intraarticular de ácido hialurónico al 2 por ciento más manitol en artrosis de rodilla durante un periodo de 6 meses / Efficacy and safety of a single intra-articular injection of 2 percent hyaluronic acid plus mannitol in knee osteoarthritis over a 6-month period

Objetivo. Evaluar la eficacia y seguridad de una única inyección intraarticular de ácido hialurónico (AH)+manitol en artrosis de rodilla (AR). Material y método. Estudio prospectivo, abierto, no-comparativo con 80 pacientes diagnosticados de AR, de los cuales 79 finalizaron el estudio. Recibieron una inyección intraarticular de 2ml de AH al 2%+manitol al 0,5% (día 0) y fueron monitorizados durante 6 meses. Los días 0, 15, 30, 60, 90, 120, 150 y 180 se evaluaron dolor y funcionalidad articular mediante una escala analógica visual (EAV) y el índice WOMAC, eficacia y seguridad según médico y paciente, y medicación de rescate como medida indirecta del dolor. Resultados. Disminución significativa del dolor articular, rigidez e incapacidad funcional en comparación con el valor inicial en todas las visitas (p<0,001). La funcionalidad articular mejoró un 38,7% 30 días tras la inyección, alcanzando un 47,5% el día 180. El consumo de medicación de rescate descendió desde un 58,2%, inicial, hasta un 2,5% el día 90, aumentando en las últimas visitas. Investigadores y pacientes valoraron positivamente eficacia y seguridad. Solamente se reportaron efectos adversos leves en 4 pacientes (dolor leve e inflamación en la zona de infiltración). Discusión. Está demostrado que inyecciones intraarticulares repetidas de AH mejoran los síntomas en AR. Sin embargo, estudios con una única inyección de AH han proporcionado resultados mixtos. Este estudio demuestra que una inyección intraarticular de AH no crosslinked mejora el dolor y la funcionalidad articular en pacientes con AR durante un periodo mínimo de 6 meses (AU)

Objective. To evaluate the safety and efficacy of a single intra-articular injection of 2% hyaluronic acid (HA)+mannitol in symptomatic knee osteoarthritis (KOA). Material and methods. Pilot, multicentre, open, non-comparative study performed in eighty patients with painful KOA, of whom 79 completed the study. They received one injection of 2ml of 2% HA+0.5% mannitol (Day 0) and were followed-up for 6 months. On Days 0, 15, 30, 60, 90, 120, 150 and 180, pain and joint function were assessed using a visual analogue scale (VAS) and WOMAC index. Efficacy and safety by investigator and patient, and rescue medication, as an indirect measure of pain, were also recorded. Results. A significant reduction in joint pain, stiffness and functional disability compared with baseline was observed at every follow-up visit (P<.001). Joint function improved by 38.7% on Day 30, reaching 47.5% on Day 180. Rescue medication use decreased from 58.2% at baseline to 2.5% on Day 90, increasing in the last visits. Efficacy and safety were positively evaluated by investigators and patients. No serious adverse events were observed. Mild side effects were reported in 4 patients (local pain and swelling in the infiltration area). Discussion. There is evidence that repeated intra-articular injections of HA improve symptoms in KOA. However, studies with a single injection of HA have shown mixed results. This study demonstrates that one single intra-articular injection of non-cross-linked HA reduces joint pain and increases function in patients with KOA over a period of at least 6 months (AU)

Two-needle vs. single-needle technique for TMJ arthrocentesis plus hyaluronic acid injections: a comparative trial over a six-month follow up.

The aim of the study was to compare the effectiveness of five weekly two-needle arthrocentesis plus hyaluronic injections vs. the same protocol performed with a single-needle technique in patients with inflammatory-degenerative disorders of the temporomandibular joint (TMJ). 80 patients with TMJ osteoarthritis were randomly assigned to the two-needle or single-needle protocol and followed up for 6 months after treatment. Several outcome parameters, such as maximum pain at rest and maximum pain on chewing, subjective chewing efficiency, limitation in jaw function, jaw range of motion in mm, were recorded at baseline and multiple follow up assessments. Both treatment groups recorded significant improvement with respect to baseline levels in almost all outcome variables. The rate of improvement was not significantly different between the treatment protocols in any of the outcome variables (p-values between 0.143 and 0.970). No between-group differences emerged for the perceived subjective efficacy (p=0.321) and the treatment tolerability (p=0.783). The present investigation did not support the existence of significant differences in the treatment effectiveness for inflammatory-degenerative TMJ disorders of a cycle of five weekly injections of arthrocentesis plus hyaluronic acid injections performed according to the classical two-needle or the single-needle technique.

[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.

[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.