Efficacy of Ultrasound-Guided Glenohumeral Joint Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Glenohumeral Osteoarthritis: A Randomized, Double-Blind Controlled Trial.

OBJECTIVE: To compare the efficacy of ultrasound-guided hyaluronic acid (HA) versus leukocyte-poor platelet-rich plasma (LP-PRP) injection in the treatment of glenohumeral osteoarthritis. DESIGN: Double-blind randomized controlled trial. SETTING: Academic institution. PATIENTS: Seventy patients with chronic glenohumeral osteoarthritis were randomly assigned to receive a single injection of HA (n = 36) or LP-PRP (n = 34). INTERVENTIONS: Leukocyte-poor platelet-rich plasma was processed using Harvest/TerumoBCT Clear PRP kits. Ultrasound-guided injections of 6 mL HA or 6 mL LP-PRP into the glenohumeral joint were performed. Patients, the injecting physician, and outcomes assessor were blinded to treatment assignments. MAIN OUTCOME MEASURES: Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) score, current/average numerical rating scale (NRS) pain scores, satisfaction, and side effects were assessed at the 5 follow-up time points over 12 months. RESULTS: Baseline characteristics were similar between groups. There were no significant between-group differences regarding SPADI, ASES, and current/average NRS pain scores at any time point up to 12 months postinjection ( P > 0.05). However, significant improvements in SPADI, ASES, and current/average NRS pain scores were observed in both groups starting at 1 or 2 months ( P < 0.01, P < 0.01, P < 0.001, and P < 0.01, respectively). These improvements were observed regardless of osteoarthritis severity. For patients who received LP-PRP, there was no effect of platelet yield on outcomes. Side effect and satisfaction rates were similar between groups. CONCLUSIONS: There were no differences in pain and functional outcomes after a single injection of LP-PRP versus HA. However, significant improvements in pain and function were observed after both treatments in patients with glenohumeral osteoarthritis.

Accuracy of ultrasound-guided superficial trigeminal nerve blocks using methylene blue in cadavers.

OBJECTIVE: To describe a technique for and assess accuracy of ultrasound-guided supraorbital, infraorbital, and mental nerve injections in a cadaveric model. Prior studies have shown that peripheral trigeminal nerve injections can be beneficial for a subgroup of patients for whom surgical treatment is not appropriate. Accurate injection is necessary to limit side effects and improve its efficacy. Ultrasound guidance may improve the accuracy of an injection that is typically performed using a blind technique. METHODS: A single operator completed 36 ultrasound-guided injections with methylene blue dye on six embalmed cadavers. Three cadavers were injected using an in-plane approach and three cadavers using an out-of-plane approach. Injections staining the target nerve were considered "accurate," whereas "inaccurate" injections resulted in no nerve staining. RESULTS: The accuracy rate was 100% (18 of 18) for the in-plane approach and 94% (17 of 18) for the out-of-plane approach. Thirty-five injections were considered accurate (97%) with overflow, and one injection was inaccurate. CONCLUSION: This cadaveric investigation suggests that ultrasound guidance can be used to inject the peripheral trigeminal nerve with a high degree of accuracy. Clinicians should consider using ultrasound guidance to inject the trigeminal nerve for diagnostic or therapeutic purposes.

Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial.

BACKGROUND: Tendinosis is a chronic degenerative condition. Current research suggests both percutaneous needle tenotomy (PNT) and leukocyte-rich platelet-rich plasma (LR-PRP) may be effective treatments for chronic tendinosis, but no studies have assessed the effectiveness of PNT alone versus PNT with intratendinous LR-PRP for multiple tendon types in a single study. OBJECTIVE: To assess the efficacy of PNT versus PNT + LR-PRP to treat chronic tendinosis. STUDY DESIGN: Double-blind, randomized, controlled comparative treatment study. SETTING: Primary academic institution. PARTICIPANTS: A convenience sample of 40 participants who had chronic tendinosis (rotator cuff, wrist extensor, wrist flexor, hip abductor, proximal hamstring, patellar, or Achilles) confirmed via ultrasound, failed conservative treatment, and did not have tendon tears, known coagulopathy, or systemic illnesses. INTERVENTIONS: Participants were randomly assigned to PNT (n = 19) or PNT + LR-PRP (n = 21). Participants and outcomes assessors were blinded to treatment assignments. PNT was performed with 20-30 passes of a 22-gauge needle under ultrasound guidance, with 1% lidocaine given outside the tendon. LR-PRP was processed from whole blood (30-60 mL) and injected into the affected tendon using the same PNT technique. MAIN OUTCOME MEASURES: Primary outcome was current numerical rating scale pain at 6 weeks. Secondary outcomes were average pain, function, general well-being, and sleep quality at 6, 52, and 104 weeks. RESULTS: Baseline characteristics were similar between groups. Overall, there were no significant differences between groups over time for any of the outcomes (P > .05). Between-group analyses showed significantly lower current and average pain after PNT compared to PNT + LR-PRP at 6 weeks (estimated-mean [SE]: 3.1[0.4] vs. 4.6[0.6], P = .04; 3.4[0.4] vs. 4.9[0.5], P = .03) only. Adverse event rates were low (PNT-3.9%; PNT + LR-PRP-5.0%) and related primarily to postprocedural pain and inflammation. CONCLUSIONS: Although pain scores were lower after PNT compared to PNT + LR-PRP at 6 weeks, there were no between-group differences in outcomes at 52 or 104 weeks.

Ultrasound-guided first metatarsophalangeal joint injections: description of an in-plane, gel standoff technique in a cadaveric study.

OBJECTIVE: To describe a longitudinal ultrasound-guided in-plane approach for injection into the first metatarsophalangeal (MTP) joint and assess its accuracy in a cadaveric model. DESIGN: A prospective anatomical cadaver study model was used. A total of 10 first MTP joints using the described technique were injected with 0.5 mL of dye under ultrasound guidance. The joints were later dissected, and accuracy was classified as accurate, accurate with overflow, or inaccurate with no injectate in the target area. RESULTS: Of the injections, 9 were classified as accurate injections, and 1 was classified accurate with overflow. CONCLUSION: This cadaveric study suggests that ultrasound-guided injections of the first MTP joint can be accurately and reproducibly performed with a gel standoff, long-axis in-plane approach. This technique attempts to minimize the collateral damage to the surrounding tissue, specifically the articular cartilage. Clinicians should consider using this technique when performing ultrasound-guided injections to the first MTP joint. LEVEL OF EVIDENCE: Cadaveric, Level V.

Piriformis syndrome, diagnosis and treatment.

Piriformis syndrome (PS) is an uncommon cause of sciatica that involves buttock pain referred to the leg. Diagnosis is often difficult, and it is one of exclusion due to few validated and standardized diagnostic tests. Treatment for PS has historically focused on stretching and physical therapy modalities, with refractory patients also receiving anesthetic and corticosteroid injections into the piriformis muscle origin, belly, muscle sheath, or sciatic nerve sheath. Recently, the use of botulinum toxin (BTX) to treat PS has gained popularity. Its use is aimed at relieving sciatic nerve compression and inherent muscle pain from a tight piriformis. BTX is being used increasingly for myofascial pain syndromes, and some studies have demonstrated superior efficacy to corticosteroid injection. The success of BTX in treating PS supports the prevailing pathoanatomic etiology of the condition and suggests a promising future for BTX in the treatment of other myofascial pain syndromes.

Exploring systems-based practice in a sample of physical medicine and rehabilitation residency programs.

OBJECTIVE: This study explores physical medicine and rehabilitation (PM&R) residents' attitudes, knowledge, and perception of health care policy in the context of systems-based practice, one of the Accreditation Council for Graduate Medical Education's core competencies for residency training. DESIGN: A cross-sectional, observational design was used via survey administration. These surveys were categorized into 6 different sections: (1) general health care policy; (2) resident awareness of and involvement in policy matters; (3) specific policy pertaining to physical medicine and rehabilitation; (4) rehabilitation alternatives to acute care; (5) documentation; and (6) educational exposure. Residents filled the survey anonymously, noting only their postgraduate year and program name for identification. SETTING: This study was conducted at 3 large PM&R residency programs in Pennsylvania, New Jersey, and New York. PARTICIPANTS: Residents participating in this study totaled 32 from Program A, 26 from Program B, and 18 from Program C. METHODS: Residents at all 3 programs were asked to complete a 34-question survey. In total, 57 surveys were evaluated. The response rates for completing the entire survey for the 3 programs were 81% (26 of 32), 73% (19 of 26), and 67% (12 of 18). The overall response rate was 75%. Not all residents at each program were given surveys to complete. MAIN OUTCOME MEASURES: This study explored resident's attitudes, knowledge, and perception of healthcare policy. Outcomes included understanding how residents feel about the extent of their general policy education, their awareness of current issues and the organizational entities that shape these policies, and whether they should be exposed to these topics within the setting of their training programs. Responses were measured on a 1 (strongly disagree) to 9 (strongly agree) scale. Specific paired t-tests were performed on select questions to further validate the responses. RESULTS: Residents uniformly agree that healthcare policy is an important aspect of medical education and should be taught within their residency programs but do not feel that they currently play an active role in affecting change (8.1 +/- 0.8 vs. 3.4 +/- 1.6, P < .001). They admit to not being aware of how to get involved but would like to delve more into these issues (3.9 +/- 1.5 vs. 7.1 +/- 1.5, P = .01). Pertaining to PM&R-specific policy, residents believe that functional ability trumps diagnosis as the most important determinant for admission to an acute inpatient facility (7.5 +/- 1.2 vs. 5.9 +/- 1.8, P < .001). Although residents see the importance of documentation, they indicate they are not adequately trained in this area (8.2 +/- 0.7 vs. 3.9 +/- 1.1, P = .04). Finally, residents acknowledge they have limited understanding of other rehabilitation delivery options or insurance companies (5.5 +/- 1.2 and 3.5 +/- 1.7). CONCLUSION: Systems-based practice is a core requirement of residency training yet has not been extensively studied. This study suggests that residents find systems-based issues important to their overall education but are not sufficiently or effectively addressed in residency. The healthcare delivery environment including PM&R is rapidly changing. It is imperative that residents are equipped with the knowledge of and ability to adapt to these changes.