Ultrasound-guided hip joint injections are more accurate than landmark-guided injections: a systematic review and meta-analysis.

AIM: To compare the accuracy of ultrasound (US)-guided versus landmark-guided hip joint injections. METHODS: PubMed, Medline and Cochrane libraries were searched up to 31 July 2014. Two independent authors selected studies assessing accuracy of intra-articular hip injections based on predetermined inclusion and exclusion criteria. Selected papers were then evaluated for quality and a meta-analysis of accuracy was performed using random effects models. RESULTS: 4 US-guided (136 hip injections) and 5 landmark-guided (295 hip injections) studies were reviewed. The weighted means for US-guided and landmark-guided hip injection accuracies were 100% (95% CI 98% to 100%) and 72% (95% CI 56% to 85%), respectively. US-guided hip injection accuracy was significantly higher than landmark-guided accuracy (p<0.0001). SUMMARY: This is the first systematic review and meta-analysis of the accuracy of US-guided versus landmark-guided hip joint injections that has revealed that US-guided injections are significantly more accurate than those that are landmark guided. Future studies should compare US with fluoroscopic-guided hip joint injections for accuracy, efficacy, safety profile, cost-effectiveness and patient satisfaction.

Honorary authorship in postgraduate medical training.

OBJECTIVES: To determine whether postgraduate medical trainees are exposed to honorary authorship, whether they are aware of the topic and if they believe that further support and education concerning this issue is needed. METHODS: Postgraduate medical trainees were contacted by email with a link to our questionnaire on two occasions (2 and 26 February 2014) and then contacted in person (June-November 2014). The questionnaire topics included demographics, authorship practice beliefs and experience, and authorship policy-related questions. We also determined the proportion of perceived, International Committee of Medical Journal Editors (ICMJE)-defined and unperceived honorary authorship in the respondent group. RESULTS: The response rate was 27.7%. The prevalence of perceived, ICMJE-defined and unperceived honorary authorship was 38.1%, 57.3% and 24.2%, respectively; 90.1% were unaware of the ICMJE authorship criteria, 92.6% were unaware of a support system for authorship disputes, but 91.8% believed such a system should be implemented and 93.3% believed medical trainees and faculty should be instructed on authorship guidelines. CONCLUSIONS: A paradigm shift from the current system is needed, where enforcement of ethical authorship practices is shifted away from journal editors. Instruction on the topic should be provided to medical trainees throughout medical school and continued during further training. A process should also be outlined to resolve authorship disputes. These measures may encourage researchers to have an open discussion on the topic prior to the commencement of a research project, and to resolve authorship conflicts in a constructive manner. We also hope this paper encourages further work on the topic.

Comparison of digital imaging screening and indirect ophthalmoscopy for retinopathy of prematurity.

The aims of this study were to determine the incidence and severity of retinopathy of prematurity (ROP) using digital imaging screening, confirm findings by indirect opthalmoscopy, and document risk factors of ROP in the neonatal intensive care unit (NICU) of a large tertiary hospital in a developing country. This prospective cohort study included infants with gestational age (GA) ≤ 32 wk, birth weight (BW) ≤ 1,500 g, or older and heavier neonates who were critically ill. Two hundred twenty two eyes (111 infants) were screened with digital imaging (Ret-Cam) and indirect ophthalmoscopy until retinal vascularization was complete or the disease regressed. Perinatal risk factors for ROP were analyzed. The overall incidence of ROP was 18.9 %. The incidence of ROP requiring treatment was 5.4 % (12/222) of the total eyes screened. Lower GA and blood transfusion were independent risk factors associated with ROP by multivariate analysis (p = 0.001, OR = 0.562, 95 % CI = 0.395-0.802, and p = 0.027, OR = 6.11, 95 % CI = 1.22-30.44, respectively). Digital imaging facilitated timely screening and detection of ROP, and enabled transfer of images, allowing early intervention for patients who required treatment.

Acetabular anteversion is associated with gluteal tendinopathy at MRI.

OBJECTIVE: Gluteal tendinopathy and greater trochanteric pain syndrome (GTPS) remain incompletely understood despite their pervasiveness in clinical practice. To date, no study has analyzed the morphometric characteristics of the hip on magnetic resonance imaging (MRI) that may predispose to gluteal tendinopathy. This study aimed to evaluate whether acetabular anteversion (AA), femoral neck anteversion (FNA), and femoral neck-shaft angle (FNSA) are associated with MRI features of gluteal tendinopathy. MATERIALS AND METHODS: A total of 203 MRI examinations of the hip met our inclusion and exclusion criteria. A single blinded investigator measured AA, FNA, and FNSA according to validated MRI techniques. Two blinded subspecialty-trained musculoskeletal radiologists then independently evaluated the presence of gluteal tendinosis, trochanteric bursitis, and subgluteal bursitis. Statistical analysis was performed using a one-way analysis of variance (ANOVA; post-hoc Tukey's range test). RESULTS: At MRI, 57 patients had gluteal tendinosis with or without bursitis, 26 had isolated trochanteric bursitis, and 11 had isolated subgluteal bursitis. AA was significantly (p = 0.01) increased in patients with MRI evidence of gluteal tendinosis with or without bursitis [mean: 18.4°, 95 % confidence interval (CI): 17.2°-19.6°] compared with normal controls (mean: 15.7°, 95 % CI: 14.7°-16.8°). Similarly, AA was significantly (p = 0.04) increased in patients with isolated trochanteric bursitis (mean: 18.8°, 95 % CI: 16.2°-21.6°). No association was found between FNA or FNSA and the presence of gluteal tendinopathy. Interobserver agreement for the presence and categorization of gluteal tendinopathy was very good (kappa = 0.859, 95 % CI: 0.815-0.903). CONCLUSION: Our MRI study suggests that there is an association between increased AA and gluteal tendinopathy, which supports a growing body of evidence implicating abnormal biomechanics in the development of this condition.

Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis.

OBJECTIVE: To compare the accuracy and efficacy of ultrasound (US)-guided injections versus landmark-guided injections of the subacromial space, biceps tendon sheath, acromioclavicular (AC) joint and glenohumeral (GH) joint. METHODS: PubMed, Medline and Cochrane libraries were searched up to 31 July 2013. Two independent authors selected and evaluated randomised controlled trials comparing the accuracy and/or efficacy of US versus landmark-guided injection of the shoulder girdle. A meta-analysis of accuracy, pain Visual Analog Scale (VAS), function score and reported adverse events were performed. RESULT: Four cadaveric studies (300 cadaveric shoulders) and nine live human studies (514 patients) were reviewed. Based on three studies for AC joint, the accuracy of US versus a landmark-guided injection was 93.6% vs 68.2% (p<0.0001). Based on single studies, the accuracy of US versus a landmark-guided injection was 65% vs 70% for the subacromial space (p>0.05), 86.7% vs 26.7% for the biceps tendon sheath (p<0.05), and 92.5% vs 72.5% for the GH joint (p=0.025). Based on three studies for the subacromial space, the US group had a significantly greater reduction in pain (mean difference (MD)=1.47, 95% CI 1.0 to 1.93), and improvement in function (standardised MD=0.70, 95% CI 0.39 to 1.01) at 6 weeks postinjection. Based on a single study for the biceps tendon sheath, the US group had a significantly greater reduction in pain (MD 1.9, 95% CI 1.2 to 2.6) and improvement in function (MD=10.9, 95% CI 6.57 to 15.23). CONCLUSIONS: US-guided injections showed greater accuracy for all shoulder girdle injections, with the exception of the subacromial space. There was improved efficacy for the subacromial space and biceps tendon sheath injections.

Feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon--A pilot cadaveric study.

OBJECTIVE: To describe an ultrasound-guided proximal percutaneous tenotomy technique of long head of the biceps tendon (LHBT). METHODS: Three fresh cadavers with no prior shoulder surgery or LHBT tears were included in the study. A single experienced musculoskeletal radiologist completed six ultrasound-guided proximal percutaneous tenotomies of LHBT. A superficial to deep approach was performed on four shoulders using an arthroscopic banana blade or retractable blade. A deep to superficial approach was performed on two shoulders using an arthroscopic hook blade. A blinded anatomist dissected each specimen and graded the tenotomy, length of proximal LHBT stump, and evidence of iatrogenic injuries. RESULTS: Four of the six cadaveric LHBTs were fully transected. The two partially transected tenotomies were performed using the arthroscopic banana and retractable serrated blades (63% and 80% transections, respectively). The proximal LHBT stump mean length was 2.6 cm (95% CI, 1.8-3.4). There was no evidence of iatrogenic lesions. CONCLUSIONS: This cadaveric study showed that the ultrasound-guided percutaneous tenotomy of the LHBT is a feasible procedure. The deep to superficial approach using an arthroscopic hook blade resulted in complete transection. Further cadaveric studies with larger numbers are warranted to confirm this novel technique's applicability in clinical practice.

MRI morphometric hip comparison analysis of anterior acetabular labral tears.

OBJECTIVE: Anterior (3 o'clock) acetabular labral tears (AALTs) have been reported to be associated with iliopsoas impingement (IPI). However, no study has examined the association between anatomical bony variables of the hip joint and AALTs. The purpose of this study was to evaluate the association between AALTs, femoroacetabular impingement (FAI) and other bony variables of the hip. MATERIAL AND METHODS: Seventy-six out of 274 hip MRI records met the inclusion criteria. Two independent blinded investigators evaluated the location of acetabular labral tears (ALTs), edema at the musculotendinous junction of the iliopsoas insertion, femoral neck anteversion angle, femoral neck shaft angle, acetabular anteversion angle, alpha angle, lateral central edge angle (LCEA), acetabular index, and acetabular depth. Comparison analyses between groups were performed. RESULTS: Twenty-two patients had no ALTs (controls), 19 patients had AALTs, and 35 patients had ALTs not isolated at the 3 o'clock position (25 with cam-bony deformities [FAI-cam] and 10 with pincer-bony deformities [FAI-pincer]). The alpha angle mean was significantly higher (p < 0.001) in the FAI-cam group (62.7º, 95 % confidence interval [CI]: 56.2-69.2º) compared with the AALTs group (46.9º, 95 % CI: 40.1-53.7º). The LCEA mean was significantly higher (p < 0.001) in FAI-pincer group (41.9º, 95 % CI: 39.3º-44.5º) compared to AALTs group (29.4º, 95 % CI: 24.2º-34.6º). There was no statistically significant difference in any of the bony variables between the controls and the AALTs group. CONCLUSION: Our study demonstrated that AALTs are pathologically distinct and not associated with FAI or other bony abnormalities. This supports the previous studies, which proposed that AALTs are associated with IPI.

Bilateral ulnar neuropathy at the elbow secondary to neuropathic arthropathy associated with syringomyelia.

Neuropathic arthropathy (NA), also known as Charcot joint, refers to a chronic progressive degenerative arthritis that is associated with an underlying central or peripheral neurologic disorder. The elbow is rarely reported to be involved in NA, but when affected, it is commonly a result of a cervical syrinx or tabes dorsalis. Few reports in the literature describe ulnar neuropathy at the elbow (UNE) associated with NA of the elbow, and none describe bilateral UNE in association with a cervicothoracic syrinx. We present a unique case of bilateral UNE resulting from NA of the elbow associated with a cervicothoracic syrinx.

The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study.

OBJECTIVE: To test the hypothesis that patients with chronic exertional compartment syndrome (CECS) of the anterior leg compartment have an increased anterior compartment thickness (ACT) compared with control subjects after exertion using ultrasound. DESIGN: Prospective comparison study. SETTING: Diagnostic imaging department of a tertiary care hospital. PATIENTS: Four patients with CECS and 9 control subjects. INTERVENTIONS: Patients with CECS and control subjects ran on a treadmill for up to 10 minutes. Anterior compartment thickness (both groups) and anterior compartment pressure (CECS patients) were measured before exertion and at scheduled intervals after exertion. MAIN OUTCOME MEASURES: Anterior compartment thickness, percentage change in ACT from rest, and compartment pressure. RESULTS: Anterior compartment pressures were diagnostic of CECS using the modified Pedowitz criteria in patients with CECS. Mean percentage change in ACT from rest in patients with CECS versus control subjects at 0.5 minutes was 21.3% versus 6.32% [95% confidence interval (CI), 6.92-35.6 and 0.094-12.5, respectively; P = 0.011]; at 2.5 minutes, it was 24.6% versus 4.22% (95% CI, 10.7-38.5 and -1.85-10.3, respectively; P = 0.003); and at 4.5 minutes, it was 24.9% versus 5.08% (95% CI, 14.3-35.5 and -0.813-11.0, respectively; P = 0.003). Mean ACT in patients with CECS versus control subjects significantly increased after exertion (P = 0.003) at 0.5 minutes, 2.5 minutes, and 4.5 minutes. CONCLUSIONS: Ultrasonography reveals a significant increase in ACT in patients with CECS of the anterior leg compartment. Further studies are warranted to validate these findings with the goal of developing anterior leg compartment CECS ultrasound diagnostic criteria and exploring the role of using ultrasound to diagnose CECS in other compartments.