B.
Gonc¸
alves
a,∗,
C.
Ambrosio
b,
S.
Serra
b,
F.
Alves
a,
A.
Gil-Agostinho
a,
F.
Caseiro-Alves
aaDepartmentofRadiology,HospitaisdaUniversidadedeCoimbra–HUC,Coimbra,Portugal bDepartmentofRheumatology,HospitaisdaUniversidadedeCoimbra–HUC,Coimbra,Portugal
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received24January2010 Accepted7April2010 Keywords: Rheumaticdiseases Interventionalradiology UltrasoundJointsteroidinjections Radiosynoviorthesis Arthrocentesis Biopsy
a
b
s
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t
Objective:Todescribethemainindicationsandthetechnicalstepstoperformultrasoundguided proce-duresinpatientswithrheumaticdiseases.Toaccessproceduresaccuracy,safetyandeffectiveness. Materialsandmethods:27patientswithpainrelatedtoarticularcomplicationsofrheumaticdiseases andaccordingtopreviousradiographicorUSexamweresubmittedtoseveralUS-guidedprocedures. 42%ofpatients(n=11)hadrheumatoidarthritis,11%(n=3)spondyloarthropathies,18%(n=5)psoriatic arthritis,15%(n=4)undifferentiatedarthritis,3%(n=1)Sjögrensyndromeand11%(n=3)hadgout.
Describedproceduresaresynovialbiopsies,intra-articularinjectionsofcorticosteroids,radiation syn-ovectomyandsynovialcystsdrainageprocedures.Whenatherapeuticalprocedurewasmade,patients wereevaluatedby2rheumatologists.
CorticosteroidsusedwerePrednisoloneandTriamcinolone.Yttrium-90wasusedforsynovectomy. Results:Inallcasessuccesswasachievedwithcorrectneedleplacementinsidethejoint.After injec-tion/aspiration symptoms successfully solved with all patients improving their health status. No complicationswererecordedduringfollow-upperiod.
Conclusions:US-guidanceisveryreliabletoaffordasafetyprocedurealwayscheckingtheinjection, biopsyoraspiration.Guided-biopsyhashighsuccessratesobtainingseveralsamples.Thusisalsopossible tousemorepowerful/longactingtherapeuticdrugsaggressivetoextra-articularstructuresavoiding complications.
© 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Ultrasound(US)guidedinterventionaltechniquesarethemost reliablewaytoaccesssafely,quicklyandaccuratelyallthejoints intheapendicularskeleton.Inseveralcasesrheumaticdiseases need the help of ultrasonography toachieve a confident diag-nosis characterizing the affected joints and evaluating disease activity. In a few cases the rheumatic disorder is only diag-nosedbysynovialbiopsyorbyjointfluidchemical andculture tests.
Duringchronictherapyrheumaticdiseasescoursewithacute exarcebations that must be promptly treated. During systemic therapy some joints alsofail to respondand thus theybenefit fromintra-articularcorticosteroidinjections.USfindingslike syn-ovialthickening, the presence of Power-Döppler signal(Fig.1) or US-contrast enhancement indicate active synovitis (Fig. 2)
∗ Correspondingauthorat:TravessadosNavegadores,Lote1,1.frente,3030-065 Coimbra,Portugal.
E-mailaddress:belarmino.goncalves@gmail.com(B.Gonc¸alves).
and are wellcorrelated with patient symptoms. US evaluation ofthesymptomaticjointsimprovestherapeuticeffectivenessof US-guidedtherapy bychoosing therightplace for injection. In those cases when a tendinitis or a tenosynovitis is present, a corticosteroid instillation in thetendon sheathcan alsoreduce synovial inflammation and improving symptoms (Fig. 3) [1]. Yttrium-90 radiationsynovectomy or radiosynoviorthesis(RSO) is another therapeutic technique based on an intra-articular image-guided infusion of a radionuclide. It intends to block intra-articular inflammation, reducing effusion, improving pain and jointswelling and thusrestoring articularmobility (Fig. 4) [2–6].
Described techniques involve an approach with ultrasound guidancetoplacetheneedleintra-articularly.Thefollowing proce-duresalsorequireathoroughknowledgeofultrasoundanatomy todecidetheoptimumintra-articular site toperformthe tech-nique. Sonographic needle guidance significantly improves the performance and outcomes in a clinically significant manner [7].
Thisworkdescribesintra-articulartechniquesguidedby ultra-soundatshoulder,elbow,wrist,metacarpophalangeal,knee,ankle andmetatarsophalangealjoints.
0720-048X/$–seefrontmatter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2010.04.001
Fig.1.Power-Döppler-US.Metatarsophalangealjointshowingsynovialthickening andDöpplersignalindicatingactivesynovitis(PsoriaticArthritis).
Fig.2.ContrastEnhancedUS(CEUS)ofthesupra-patelarrecessshowingearly synovialenhancementandthusdiagnosingactivesynovitis(Sjögrensyndrome). Enhancementtimeisdisplayedintherightinferiorcorneroftheimage(19s). Enhancementregioninthesynoviumisdemarcatedbythewhiteline.
Fig.3.Corticosteroidinjection– patientwithearlyRheumatoidarthritis.USshows tenosynovitisinthetibialisposteriortendon.Methylprednisoloneisbeinginjected inthetendonsheath.21Gneedle(arrow).The(*)indicatestheairbubblesofthe injectionmixture.
2. Materialandmethods
2.1. Patientselection
27 patients with pain related to articular complications of rheumaticdiseasesandaccordingtopreviousradiographicorUS examweresubmittedtothefollowingUS-guidedprocedures.
42%of patients(n=11) had rheumatoidarthritis, 11% (n=3) spondyloarthropathies,18% (n=5) psoriaticarthritis,15% (n=4) undifferentiatedarthritis, 3% (n=1)Sjögren syndromeand 11% (n=3)hadgout.
2.2. Procedures,articularpunctureandjointspecificfeatures 1.Synovialbiopsywasmadein3patients.
2.Arthrocentesis/cystsdrainagewasmadein8patients. 3.Corticosteroidinjectionsin12patients.
4.Radiationsynovectomy(Yttrium-90)–USguidedin4patients.
Fig.5.Synovialbiopsy–patientwithanundifferentiatedoligoarthritis.USshows the18Gneedle(arrow)enteringthethickenedsynovium(hypoechoic)inthe supra-patellarrecess.
Alltheproceduresweredoneunderstrictasepticconditions. Itisveryimportanttouseallultrasoundanatomicallandmarks. Puncturetechniquewasperformedaccordingtheradiologist expe-rienceandsometimesusingasimilartechniqueasinCT orMR arthrography[8].Localskinanesthesiawasperformedalmostinall procedures,particularlyinthesynovialbiopsy.Alidocainesolution (1%)wasinjectedundertheskinwithoutairbubblesinthesyringe toavoidultrasoundartifacts.Thearticularspaceisverywidein theknee,shoulderandelbowandrelativelysmallinthewristand phalangealjoints.Weuseda21gauge×40mmneedleintheknee, elbowandintheankleanda23gauge×25mmneedleinthewrist, metacarpophalangealandinthemetatarsophalangealjoints.Inthe shoulderwasusedaspinalneedle(21gauge×70mm). Yttrium-90radiosynoviorthesiswasonlymadeintheknee.Corticosteroids usedwere:
1. Triamcinolonehexacetonideisarelativelyinsoluble corticos-teroidwithaprolongedeffectontissueatthelocalinjectionsite andthedurationusuallyrangingfromafewweekstoseveral months.
2. Methylprednisolone acetate wasused for short-term admin-istration and to tide the patient over an acute episode or exacerbation.
2.3. Indicationsandtechniques 2.3.1. Synovialbiopsy
Themainindicationstosynovialbiopsywere:
• Todistinguishaninflammatoryfromaninfectiousarthropathy, particularlywhenthereisanoligoarthritis.
• Tomakethedifferentialdiagnosisfromothersynovial thicken-ingconditionslikepigmentedvillonodularsynovitis(PVNS)ora metabolicarthropathy(crystaldepositiondisease)(Fig.5).
Materialused:
• Sterilegloves,surgicalgauzeanddrapes. • Cleaningfluid–alcoholoriodinesolution. • 18-gaugethru-cutneedle.
• 10mLbottleof0,9%sodium-chloridesolution. • 10mLbottleofformaldehydesolution.
• Two50mLrecipientsforsamples(oneforsodium-chlorideand otherforformaldehydesolution).
Fig.6. Arthrocentesis– patientwithanundifferentiatedoligoarthritis.USshows theneedleenteringthesupra-patellarrecesstoaspiratefluid.
Fig.7.Corticosteroidinjection(triamcinolone)–patientwithanundifferentiated oligoarthritis.USshowstheneedleenteringthesupra-patellarrecessandbubbling effectofthedrug.Airbubblespresentintheinjectionmixture(arrow).
2.3.2. Arthrocentesis/cystsdrainage
Themainindicationsofguidedarthrocentesiswere(Fig.6): • To characterize the aetiology of a monoarthritis, particularly
whenthereisasmallamountoffluid.
• Tocomplementsynovialbiopsyinthestudyofanoligoarthritis (forchemicalandculturetestsofthesynovialfluid).
• Todrainsynovialcysts. • Toreliefrelatedsymptoms.
Materialused:
• Sterilegloves,surgicalgauzeanddrapes. • Cleaningfluid–alcoholoriodinesolution. • 21-ora23-gaugeneedleaccordingtothejoint. • 5mLsyringe(s).
• 50mLsterilerecipientforfluid. 2.3.3. Corticosteroidinjections
Themainindicationsofintra-articularcorticosteroidinjections were(Fig.7):
Fig.8.Materialusedforradiosynoviorthesis(RSO).
• Totreatsynovialproliferationwhenitfailstorespondtosystemic therapyandthusreducingearlyjointdestruction.
• Toreducerelapsingeffusionsandtopreventsynovialcysts recur-rence.
Materialused:
• Sterilegloves,surgicalgauzeanddrapes. • Cleaningfluid–alcoholoriodinesolution. • 21-ora23-gaugeneedleaccordingtothejoint. • One2mLsyringe.
• 40mgofmetilprednisolone(80mginbiggerjoints)or20mgof triamcinolonehexacetonide(40mginbiggerjoints).
2.3.4. Radiosynoviorthesis– USguided ThemainindicationsforRSO-Y90were:
• Persistentmonooroligoarthritisunresponsivetomedical treat-mentoverthelast6months.
• Intolerancetomedicaltreatment.
• Absence of response to an effective dose of intra-articular steroids.
• Absenceofanyabsolutecontraindication(pregnancy,lactation afterpregnancy,skininfection,articularinfection,bonefracture, poplitealcystwithrupturesigns,severehemarthrosis).
Materialused:
• Sterilegloves,surgicalgauzeanddrapes. • Cleaningfluid–alcoholoriodinesolution. • 10mLbottleof0,9%sodium-chloridesolution.
• 1mLsyringe(forYttrium)andtwo5mLsyringes(for sodium-chloridesolutionandforsteroid).
• 21-gaugeneedle.
• 3-waystopcockwitha10cmextensiontube(Fig.8).
• Yttrium-90solutionof185MBqwithisolatingmaterialaround syringe(Fig.9).
• 40mgofmetilprednisolone(administeredtoreduceflareafter radionuclideinfusion).
2.4. Clinicalevaluation
Whenatherapeuticprocedurelikecorticosteroidsinjectionsor radiationsynovectomywasmadepatientswereevaluatedbytwo
Fig.9. AspirationofYttrium-90fromcontainer.Isolatingmaterialaroundsyringe.
Fig.10.VisualAnalogScale(VAS)forpain.
rheumatologists.Patientswereevaluatedat3weeksand6months. Theclinicaleffectwasassessedbyevaluatingstiffness,swelling, effusionandspontaneousormechanicalpain.Aquestionnairescale wasalsoapplied– VisualAnalogScale(VAS)forpain(Fig.10).
3. Results
3.1. Proceduredetails
Withpatientpositionedontheultrasoundexaminationtable andusinganaseptictechniquethesurfacepuncturewascleaned (withalcoholoriodinesolution).Totheintra-articularplacementof theneedleallultrasoundanatomicallandmarkswereused, avoid-ingvessels,tendonsorligaments.Oncethejointwasenteredand littleresistancetoinjectionwasfeltintra-articularplacementwas achieved.Becauseoftheradiopharmaceuticaldrug(Yttrium-90) synovectomyrequiredspecificfeaturesforradiationprotection. 3.1.1. Shoulder
Patientwasplacedseatedwiththeshouldersadductedin neu-tralposition.Aposteriorapproachwasused(Fig.11).TheUS-probe wasplacedparalleltoinfraspinatustendonwiththetipofthe nee-dleadvancedtothehumeralheadjustlaterallytotheposterior labrum(Fig.12).Otherapproachescanbeusedaccordingtothe radiologistexperience[9,10].
3.1.2. Elbow
Patientwasplacedseated withtheelbowslightly extended. Theprobewasplacedlongitudinallyshowinganteriorjointrecess (Fig.13).Thetipoftheneedleadvancedtothehumeraltrochlea (Fig.14).
3.1.3. Wrist
Patientwasplacedseatedwiththeelbowextendedandwrist pronatedonatable.Radiocarpalcompartmentwasalwaysused. Theprobewasplacedlongitudinallyalongthearticularspacealong de radiusand scapholunate space, about 1cm distal to Lister’s tubercle,withtheneedlemakingaproximaltiltofapproximately 10–30◦andbetweentheextensorpollicislongusandextensor dig-itorumcommunis(Figs.15and16)[11].
Fig.11. US-probepositiontopunctureshoulderjoint.Askinmarkindicates punc-turesitetoenterthegleno-humeraljoint.
Fig.12.USimageshowsthedirectionoftheneedletoenterthejointspacebetween thehumeralheadanthelabrum.Infraspinatustendon(InfS)andGlenoidlabrum (Lab).
Fig.13.US-probepositiontoentertheanteriorrecessoftheelbowjointspace.
Fig.14.Corticosteroidinjection –patientwith aPsoriaticarthritis. USshows markedsynovialthickeningandthetipoftheneedleintheanteriorjointrecess.
Fig.15.US-probepositiontoenterthewristjointspace(radiocarpalcompartment).
Fig.16.PatientwithalateRheumatoidarthritis.USshowstheneedleadvancing troughtheradiocarpalcompartmentofthewrist(arrows).
3.1.4. Metacarpophalangealjoints
Patient was placed seated with the elbow extended, wrist pronated and fingers extended on a table. The probe was place in a longitudinal dorsoradial or dorsoulnar position along the articular space (Fig. 17). The needle was advanced avoiding extensor tendons. A subtle tractionin opposite
direc-Fig.17.US-probepositiontopunctureametacarpophalangealjoint(3rdfinger).
Fig.19. Radiosynoviorthesis(RSO)procedurebylateralapproach.Materialusedfor radiationprotection.
tion of the needle was helpful to slightly open the joint space.
3.1.5. Knee
Patientwasplacedseatedonanexaminationtablewiththeknee flexed(30◦)andankleextended.Accordingtotheprocedurelateral (Fig.19),anterior(abovepatella)(Figs.7,18,20and21)or poste-riorapproacheswereused.Whenanteriorapproachwasneeded theneedlewasinsertedintothesofttissuedirectedtothe supra-patellarrecessorwhenaposteriorapproachwasneededtheneedle wasdirectedtothepoplitealcyst(Fig.22)[12].
3.1.6. Ankle
Patientwasplacedseatedonanexaminationtablewiththeknee flexed(45◦)andankleextended.Placingthetransducerprobe lon-gitudinallyalong thetibiaandthetalus,anteromedialapproach wasusedwiththeneedlebetweentheanteriortibialistendonand themedialmalleolus(Fig.23).
3.1.7. Metatarsophalangealjoints
Patientwasplacedseatedonanexaminationtablewiththeknee flexed(45◦),ankleandfingersextended.Theprobewasplaceina longitudinaldorso-lateralordorso-medialpositionalongthe artic-ularspace(Fig.24).Theneedlewasadvancedavoidingextensor tendons.Asubtletractioninoppositedirectionoftheneedlewas helpfultoslightlyopenthejointspace(Fig.25).
Fig.18.Radiosynoviorthesis(Yttrium-90).USimageshowstheneedleinthe supra-patellarjointrecess.
Fig.20.US-probepositiontoenterthekneejointspace(supra-patellarrecess).A skinmarkindicatespuncturesite.
Fig.21.Synovialbiopsy– patientwithanundifferentiatedoligoarthritis.USshows theneedleenteringthethickenedsynoviuminthesupra-patellarrecess.
Fig.22. Corticosteroidinjection–patientwithrheumatoidarthritis.USshowsa poplitealcystbeinginjectedwithmethylprednisoloneafterdrainage.Arrow indi-catestheneedle.
Fig.23.US-probepositiontoentertheanklejointspace.Askinmarkindicates puncturesite.
Fig.24. US-probepositionto punctureametatarsophalangealjoint(1stfinger shown).
Fig.25.Corticosteroidinjection (methylprednisolone).Patient withaPsoriatic arthritiswiththickenedsynovium(*).USshowsaninjectioninthe2nd metatar-sophalangealjoint.Arrowindicatestheairbubblingeffect.
3.2. Technicaloutcome
Theoverallsuccessratewas100%(n=27).Inallcasessuccess wasachievedwithcorrectneedleplacementinsidethejoint.No complicationsoccurredintheinfusionorwithinfollow-upperiod asvasovagalreactionsorjointinfection.
3.3. Clinicaloutcome
Allpatients(n=27)improvedtheirstatussolvingswellingand tenderness, with improvement in VAS for pain. No short-term clinicaladverseside effectswerenoted. Nocomplications were recordedduringthefollow-upperiodof6months.
4. Discussion/conclusion
US-guidanceisveryreliabletoaffordasafetyprocedurealways checkingtheinjection,biopsyoraspiration.Guided-biopsyhashigh successrates obtainingseveralsamples.Thusisalsopossibleto safely usemore powerful/longactingtherapeutic drugs aggres-sivetoextra-articularstructureslikeTriamcinoloneorYttrium-90. Inclinicalterms,therapeuticproceduresunderUS-guidance,are short-term useful and very safe options in persistent synovitis unresponsivetoconventionaltherapy.
Conflictsofinterest/disclaimer
The authors declarethat thesubmitted article is not under considerationforpublicationelsewhereandthattheyhave par-ticipatedsufficientlyinthisstudytotakepublicresponsibilityfor itscontent.
Alltheauthorsortheirinstitutionshavenoconflictsofinterest, financialorpersonalrelationshipsthatinappropriatelyinfluence theiractionsregardingthisarticle.
Acknowledgements
We thank to Gracinda Costa, MD and Pedro Abreu, MDby theirsupportin theRadiosynoviorthesis.Wethank alsotoLara Rodrigues,MDforthehelpintheprovidedillustrations.
References
[1]JeyapalanK,ChoudharyS.Ultrasound-guidedinjectionoftriamcinoloneand bupivacaineinthemanagementofDeQuervain’sdisease.SkeletalRadiol 2009;38(November(11)):1099–103.
