EVIDENCE-BASED MEDICINE
Evidence-Based Medicine
Ultrasound Guidance of Steroid Injections Jason Clain, BS, Matthew I. Leibman, MD, Mark R. Belsky, MD, David E. Ruchelsman, MD THE PATIENT A 58-year-old woman presents with increasing pain at the base of the right thumb. She has discomfort during activities of daily living such as buttoning a shirt and gripping tools while gardening. She is diagnosed with trapeziometacarpal (TMC) arthrosis and is interested in nonsurgical management. Her friend recently had a corticosteroid injection using ultrasound (US) guidance. THE QUESTION Can US guidance improve the accuracy and efficacy of corticosteroid injections? CURRENT OPINION Hand surgeons often offer corticosteroid injections to their patients.1e5 In uncontrolled studies patients report improvement of symptoms after both blind (palpation-guided) and sonographically guided injections,2,6e9 but it is not clear whether corticosteroid or hyaluronate injections are better than placebo injections.10 The use of US for guiding injections is thought to have several advantages including direct visualization of anatomy, increased accuracy, and decreased procedural pain, leading to the hope of increased effectiveness. Other surgeons wonder about the added costs. THE EVIDENCE The wrist A meta-analysis of data from 4 trials comparing intraarticular steroid injections in the wrist (radiocarpal or midcarpal not specified) done with and without US From Hand Surgery, P.C., Newton-Wellesley Hospital/Tufts University School of Medicine; the Division of Hand Surgery, Newton-Wellesley Hospital, Boston, MA. Received for publication September 4, 2014; accepted in revised form September 26, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David E. Ruchelsman, MD, 2000 Washington Street, Blue Building, Suite 201, Newton, MA 02462; e-mail: [email protected]. 0363-5023/14/3912-0025$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.09.027
2498
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
guidance (2 with blinding)11 found greater reduction of pain with US-guided procedures (Table 1).12 With the exception of a study by Sibbit and colleagues,13 the studies included in this meta-analysis failed to reach individual statistical significance. Of these 5 articles, one of the co-authors on the Cunnington study reported consulting fees from Abbott and SonoSite totaling less than $20,000.14 Observational studies using radiopaque dye and radiographs reported that palpation-guided injections of the wrist (radiocarpal or midcarpal not specified) are accurately placed between 50% and 97% of the time (Table 2).6,15e17 More recently, randomized, double-blind studies by Luz et al18 (radiocarpal or midcarpal not specified) and Cunnington et al14 (radiocarpal, midcarpal, and radioulnar joints) directly compared the accuracy of palpation-guided versus sonographically guided injections in the wrist using radiopaque dye and radiographs. These prospective studies found no significant difference in anatomic placement when the 2 methods of injection were compared (Table 1). Carpal tunnel A prospective study randomized 46 patients to USguided or standard injection of the carpal tunnel.9 Patients were evaluated using the Boston Carpal Tunnel Questionnaire by physicians who were not aware of the patients’ cohort assignment. They found significantly better relief of symptoms 12 weeks after injection when US was used. Makhlouf et al19 randomized 77 patients to either US-guided or standard injection of the carpal tunnel. In this non-blinded trial, the researchers found that the US-guided injection group had a 77% greater reduction in procedural pain and 63% greater reduction in symptoms measured 6 months after injection. TMC joint In a cadaveric study, 16 of 17 US-guided injections entered the TMC joint.20 Helm et al reported a prospective observational study of 60 patients undergoing palpation-guided TMC joint injections in which the needle was inserted using traditional methods and its placement was
TABLE 1. Differences in Accuracy and Clinical Outcomes in Studies Directly Comparing US-Guided Injection and Palpation-Guided Injection
Author (Date) Dubreuil et al
11
(2013)
Site
Subjects, n
Wrist (meta-analysis)
Was US Significantly More Accurate?
Were Clinical Outcomes of US Significantly Better?
202
Yes (P < .050)
(2011)*
Wrist
83
Yes (P ¼ .030)
Sibbit et al13 (2009)*
Wrist
30
No (P ¼ .840)
Wrist
60
No (P ¼ 1.00)
No (P ¼ .060)
Wrist
30
No (P ¼ .817)
No (P ¼ .230)
Carpal tunnel
77
Yes (P ¼ .001)
Carpal tunnel
46
Yes (P ¼ .007)
Sibbit et al Luz et al
12
18
(2008)*
Cunnington et al14 (2010)* Makhlouf et al
19
(2013)
Üstün et al9 (2013) Kume et al
24
(2012)
Yes (P < .001)
First dorsal compartment
44
Nam et al7 (2013)
Distal radioulnar joint
60
Yes (P < .050)
Raza et al28 (2003)
MCP joint
32
Yes (P < .050)
Raza et al28 (2003)
PIP joint
38
Yes (P < .050)
†
Lee et al (2011)
A1 pulley
40
Yes (P ¼ .001)
Smith et al4 (2011)†
Scaphotrapeziotrapezoidal
40
Yes (P < .050)
2
MCP, metacarpophalangeal; PIP, proximal interphalangeal. 11 *Included in meta-analysis of Dubeuil et al. †Cadaver study.
TABLE 2. Observational Studies Reporting Accuracy of Either US-Guided or Palpation-Guided Injections in Hand and Wrist Article
Subjects, n
Desired Injection Site
Imaging Guidance
Accuracy
Helm et al21
60
TMC
None
58.00%
Mandl et al15
32
Carpometacarpal
None
100.00%
Lopes et al6
39
MCP
None
97.00%
Lopes et al6
37
“Wrist”
None
97.00%
17
8
“Wrist”
None
50.00%
Jones et al17
3
Thumb carpometacarpal
None
0%
17
1
MCP
None
0%
Jones et al17
1
Distal interphalangeal
None
0%
Zingas et al22
19
Flexor digitorum communis
None
84.21%
Di Sante et al16
31
TMC
US
100.00%
Jones et al Jones et al
MCP, metacarpophalangeal.
then evaluated with biplanar fluoroscopy.21 That study reported that the joint space was accurately injected only 58% of the time (Table 1).21 We are not aware of any studies that compare USguided and standard TMC steroid injections. de Quervain tendinopathy In a single-arm, prospective, double-blind study, Zingas and colleagues22 used a mixture of steroid, anesthetic, and radiopaque dye to examine the accuracy of palpation-guided first dorsal compartment injections. J Hand Surg Am.
r
Hand surgeons injected the medication and radiologists who were blinded to the surgeons’ technique examined the accuracy on radiographs. Patients were observed for 3 months and follow-up results were recorded by clinicians who were blinded to the radiologists’ interpretation. In this trial, the researchers found that injection of the first dorsal compartment was accurately placed 84% of the time and that marked relief was reported in 57% of patients. Hajder et al23 reported a retrospective, single-arm series of 71 wrists with de Quervain tendinopathy Vol. 39, December 2014
Evidence-Based Medicine
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ULTRASOUND GUIDANCE OF STEROID INJECTIONS
Evidence-Based Medicine
injected with corticosteroids under US guidance. A total of 73% of patients experienced relief after one injection, and 91% with a second injection. Compared with averages reported in the literature, the authors thought that US-guided injections were better for the second injection but not the initial one. In a randomized, controlled study of 44 patients with de Quervain tendinopathy, patients were randomized to receive either US-guided or palpationguided injections. Symptoms and disability were recorded electronically by a rheumatologist blinded to the patients’ cohort assignment. Patients receiving USguided injections reported less pain 4 weeks after injection than did patients receiving standard injections.24 Trigger finger In a cadaver study, trigger finger injections were completely contained within the tendon sheath in 70% of US-guided injections compared with 15% of standard injections, and 30% of the standard injections resulted in dye found in the tendon.2,25 In 2009, Bodor and Flossman26 used US-guided corticosteroid injection for trigger finger and reported that 90% had no triggering 6 months after injection and 71% had no triggering 3 years after injection. A retrospective review of 112 patients with trigger thumb treated with US-guided injections evaluated one year later found that 86% had no triggering after one injection.27 MCP and PIP joints In a study of 70 patients, the accuracy of USguided and palpation-guided needle placement in the metacarpophalangeal (MCP) and PIP joints was evaluated by a musculoskeletal ultrasonographer using high-resolution ultrasound.28 The radiographic evaluation was done simultaneously with the procedure (performed by a rheumatologist); however, there was no blinding. Ultrasound-guided injections were accurately placed in 100% of MCP joints and 92.3% of PIP joints. This was significantly better than palpation-guided injections, which were 80% accurate in MCP joints and 50% accurate in PIP joints (P < .05) (Table 1).28 SHORTCOMINGS OF THE EVIDENCE There is no evidence that corticosteroid injection is better than placebo injection for most of these conditions. Studies of US-guided injections are limited largely to uncontrolled cohorts and anatomical studies. Sham US-guided controls and blinding of subjects is notably absent in most studies. There are no cost-benefit analyses. The lack of such studies is J Hand Surg Am.
r
surprising given how common these conditions are. Although overt conflicts of interest were uncommon, the reader should assume that these studies are likely done by enthusiasts and advocates of US and should be aware that many physicians bill for US and profit from it. DIRECTIONS FOR FUTURE RESEARCH Double-blind, placebo-controlled, prospective, randomized trials are needed to determine whether corticosteroid injections are more effective than placebo injections for these hand and wrist conditions. If we can establish that corticosteroid injections are truly palliative or disease-modifying, we can determine the role of US compared with palpation-guided corticosteroid injections for various hand and wrist pathologies using additional randomized trials employing sham US, independent evaluators, and other methods to minimize bias. Dispassionate researchers who do not stand to benefit from the results should conduct these studies. OUR CURRENT CONCEPTS FOR THIS PATIENT We find the potential for US guidance to improve the accuracy of injections of tendon sheaths and small joints appealing. We inform patients about the added cost and our added profit (conflict of interest) associated with US in the setting of limited evidence of improved palliation or disease modification, and allow each patient to make an informed decision. REFERENCES 1. Gilliland CA, Salazar LD, Borchers JR. Ultrasound versus anatomic guidance for intra-articular and periarticular injection: a systematic review. Phys Sportsmed. 2011;39(3):121e131. 2. Lee D-H, Han S-B, Park J-W, Lee S-H, Kim K-W, Jeong W-K. Sonographically guided tendon sheath injections are more accurate than blind injections: implications for trigger finger treatment. J Ultrasound Med. 2011;30(2):197e203. 3. Orlandi D, Corazza A, Silvestri E, et al. Ultrasound-guided procedures around the wrist and hand: how to do. Eur J Radiol. 2014;83(7):1231e1238. 4. Smith J, Brault JS, Rizzo M, Sayeed YA, Finnoff JT. Accuracy of sonographically guided and palpation guided scaphotrapeziotrapezoid joint injections. J Ultrasound Med. 2011;30(11):1509e1515. 5. Grassi W, Farina A, Filippucci E, Cervini C. Sonographically guided procedures in rheumatology. Semin Arthritis Rheum. 2001;30(5): 347e353. 6. Lopes R, Furtado R, Parmigiani L, Rosenfeld A, Fernandes A, Natour J. Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology (Oxford). 2008;47(12):1792e1794. 7. Nam SH, Kim J, Lee JH, Ahn J, Kim YJ, Park Y. Palpation versus ultrasound-guided corticosteroid injections and short-term effect in the distal radioulnar joint disorder: a randomized, prospective singleblinded study. Clin Rheumatol. 2013 Aug 11. [Epub ahead of print]. 8. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided
Vol. 39, December 2014
9.
10. 11.
12.
13.
14.
15.
16.
17.
18.
injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004;31(2):308e314. Üstün N, Tok F, Yagz AE, et al. Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: a single-blind randomized prospective study. Am J Phys Med Rehabil. 2013;92(11):999e1004. Wolf JM. Injections for trapeziometacarpal osteoarthrosis. J Hand Surg Am. 2010;35(6):1007e1009. Dubreuil M, Greger S, LaValley M, Cunnington J, Sibbitt WL Jr, Kissin EY. Improvement in wrist pain with ultrasound-guided glucocorticoid injections: a meta-analysis of individual patient data. Semin Arthritis Rheum. 2013;42(5):492e497. Sibbitt WL Jr, Band PA, Chavez-Chiang NR, Delea SL, Norton HE, Bankhurst AD. A randomized controlled trial of the cost-effectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. J Rheumatol. 2011;38(2):252e263. Sibbitt WL, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36(9):1892e1902. Cunnington J, Marshall N, Hide G, et al. A randomized, doubleblind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum. 2010;62(7):1862e1869. Mandl LA, Hotchkiss RN, Adler RS, Ariola LA, Katz JN. Can the carpometacarpal joint be injected accurately in the office setting? Implications for therapy. J Rheumatol. 2006;33(6):1137e1139. Di Sante L, Cacchio A, Scettri P, Paoloni M, Ioppolo F, Santilli V. Ultrasound-guided procedure for the treatment of trapeziometacarpal osteoarthritis. Clin Rheumatol. 2011;30(9):1195e1200. Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ. 1993;307(6915):1329. Luz K, Furtado R, Nunes C, Rosenfeld A, Fernandes A, Natour J. Ultrasound-guided intra-articular injections in the wrist in patients with rheumatoid arthritis: a double-blind, randomised controlled study. Ann Rheum Dis. 2008;67(8):1198e1200.
J Hand Surg Am.
r
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19. Makhlouf T, Emil NS, Sibbitt WL Jr, Fields RA, Bankhurst AD. Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance. Clin Rheumatol. 2014;33(6): 849e858. 20. Umphrey GL, Brault JS, Hurdle M-FB, Smith J. Ultrasoundguided intra-articular injection of the trapeziometacarpal joint: description of technique. Arch Phys Med Rehabil. 2008;89(1): 153e156. 21. Helm A, Higgins G, Rajkumar P, Redfern D. Accuracy of intraarticular injections for osteoarthritis of the trapeziometacarpal joint. Int J Clin Pract. 2003;57(4):265e266. 22. Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de Quervain’s tendinitis. J Hand Surg Am. 1998;23(1):89e96. 23. Hajder E, de Jonge M, van der Horst C, Obdeijn M. The role of ultrasound-guided triamcinolone injection in the treatment of De Quervain’s disease: treatment and a diagnostic tool? Chirurgie de la Main. 2013;32(6):403e407. 24. Kume K, Amano K, Yamada S, Kuwaba N, Ohta H. In de Quervain’s with a separate EPB compartment, ultrasound-guided steroid injection is more effective than a clinical injection technique: a prospective open-label study. J Hand Surg Eur Vol. 2012;37(6): 523e527. 25. Taras JS, Iilams GJ, Gibbons M, Culp RW. Flexor pollicis longus rupture in a trigger thumb: a case report. J Hand Surg Am. 1995;20(2): 276e277. 26. Bodor M, Flossman T. Ultrasound-guided first annular pulley injection for trigger finger. J Ultrasound Med. 2009;28(6):737e743. 27. Mardani-Kivi M, Lahiji FA, Jandaghi AB, Saheb-Ekhtiari K, HashemiMotlagh K. Efficacy of sonographically guided intra-flexoral sheath corticosteroid injection. Acta Orthop Traumatol Turc. 2012;46(5): 346e352. 28. Raza K, Lee C, Pilling D, et al. Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology (Oxford). 2003;42(8):976e979.
Vol. 39, December 2014
Evidence-Based Medicine
ULTRASOUND GUIDANCE OF STEROID INJECTIONS
Evidence-Based Medicine
Ultrasound Guidance of Steroid Injections Jason Clain, BS, Matthew I. Leibman, MD, Mark R. Belsky, MD, David E. Ruchelsman, MD THE PATIENT A 58-year-old woman presents with increasing pain at the base of the right thumb. She has discomfort during activities of daily living such as buttoning a shirt and gripping tools while gardening. She is diagnosed with trapeziometacarpal (TMC) arthrosis and is interested in nonsurgical management. Her friend recently had a corticosteroid injection using ultrasound (US) guidance. THE QUESTION Can US guidance improve the accuracy and efficacy of corticosteroid injections? CURRENT OPINION Hand surgeons often offer corticosteroid injections to their patients.1e5 In uncontrolled studies patients report improvement of symptoms after both blind (palpation-guided) and sonographically guided injections,2,6e9 but it is not clear whether corticosteroid or hyaluronate injections are better than placebo injections.10 The use of US for guiding injections is thought to have several advantages including direct visualization of anatomy, increased accuracy, and decreased procedural pain, leading to the hope of increased effectiveness. Other surgeons wonder about the added costs. THE EVIDENCE The wrist A meta-analysis of data from 4 trials comparing intraarticular steroid injections in the wrist (radiocarpal or midcarpal not specified) done with and without US From Hand Surgery, P.C., Newton-Wellesley Hospital/Tufts University School of Medicine; the Division of Hand Surgery, Newton-Wellesley Hospital, Boston, MA. Received for publication September 4, 2014; accepted in revised form September 26, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David E. Ruchelsman, MD, 2000 Washington Street, Blue Building, Suite 201, Newton, MA 02462; e-mail: [email protected]. 0363-5023/14/3912-0025$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.09.027
2498
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
guidance (2 with blinding)11 found greater reduction of pain with US-guided procedures (Table 1).12 With the exception of a study by Sibbit and colleagues,13 the studies included in this meta-analysis failed to reach individual statistical significance. Of these 5 articles, one of the co-authors on the Cunnington study reported consulting fees from Abbott and SonoSite totaling less than $20,000.14 Observational studies using radiopaque dye and radiographs reported that palpation-guided injections of the wrist (radiocarpal or midcarpal not specified) are accurately placed between 50% and 97% of the time (Table 2).6,15e17 More recently, randomized, double-blind studies by Luz et al18 (radiocarpal or midcarpal not specified) and Cunnington et al14 (radiocarpal, midcarpal, and radioulnar joints) directly compared the accuracy of palpation-guided versus sonographically guided injections in the wrist using radiopaque dye and radiographs. These prospective studies found no significant difference in anatomic placement when the 2 methods of injection were compared (Table 1). Carpal tunnel A prospective study randomized 46 patients to USguided or standard injection of the carpal tunnel.9 Patients were evaluated using the Boston Carpal Tunnel Questionnaire by physicians who were not aware of the patients’ cohort assignment. They found significantly better relief of symptoms 12 weeks after injection when US was used. Makhlouf et al19 randomized 77 patients to either US-guided or standard injection of the carpal tunnel. In this non-blinded trial, the researchers found that the US-guided injection group had a 77% greater reduction in procedural pain and 63% greater reduction in symptoms measured 6 months after injection. TMC joint In a cadaveric study, 16 of 17 US-guided injections entered the TMC joint.20 Helm et al reported a prospective observational study of 60 patients undergoing palpation-guided TMC joint injections in which the needle was inserted using traditional methods and its placement was
TABLE 1. Differences in Accuracy and Clinical Outcomes in Studies Directly Comparing US-Guided Injection and Palpation-Guided Injection
Author (Date) Dubreuil et al
11
(2013)
Site
Subjects, n
Wrist (meta-analysis)
Was US Significantly More Accurate?
Were Clinical Outcomes of US Significantly Better?
202
Yes (P < .050)
(2011)*
Wrist
83
Yes (P ¼ .030)
Sibbit et al13 (2009)*
Wrist
30
No (P ¼ .840)
Wrist
60
No (P ¼ 1.00)
No (P ¼ .060)
Wrist
30
No (P ¼ .817)
No (P ¼ .230)
Carpal tunnel
77
Yes (P ¼ .001)
Carpal tunnel
46
Yes (P ¼ .007)
Sibbit et al Luz et al
12
18
(2008)*
Cunnington et al14 (2010)* Makhlouf et al
19
(2013)
Üstün et al9 (2013) Kume et al
24
(2012)
Yes (P < .001)
First dorsal compartment
44
Nam et al7 (2013)
Distal radioulnar joint
60
Yes (P < .050)
Raza et al28 (2003)
MCP joint
32
Yes (P < .050)
Raza et al28 (2003)
PIP joint
38
Yes (P < .050)
†
Lee et al (2011)
A1 pulley
40
Yes (P ¼ .001)
Smith et al4 (2011)†
Scaphotrapeziotrapezoidal
40
Yes (P < .050)
2
MCP, metacarpophalangeal; PIP, proximal interphalangeal. 11 *Included in meta-analysis of Dubeuil et al. †Cadaver study.
TABLE 2. Observational Studies Reporting Accuracy of Either US-Guided or Palpation-Guided Injections in Hand and Wrist Article
Subjects, n
Desired Injection Site
Imaging Guidance
Accuracy
Helm et al21
60
TMC
None
58.00%
Mandl et al15
32
Carpometacarpal
None
100.00%
Lopes et al6
39
MCP
None
97.00%
Lopes et al6
37
“Wrist”
None
97.00%
17
8
“Wrist”
None
50.00%
Jones et al17
3
Thumb carpometacarpal
None
0%
17
1
MCP
None
0%
Jones et al17
1
Distal interphalangeal
None
0%
Zingas et al22
19
Flexor digitorum communis
None
84.21%
Di Sante et al16
31
TMC
US
100.00%
Jones et al Jones et al
MCP, metacarpophalangeal.
then evaluated with biplanar fluoroscopy.21 That study reported that the joint space was accurately injected only 58% of the time (Table 1).21 We are not aware of any studies that compare USguided and standard TMC steroid injections. de Quervain tendinopathy In a single-arm, prospective, double-blind study, Zingas and colleagues22 used a mixture of steroid, anesthetic, and radiopaque dye to examine the accuracy of palpation-guided first dorsal compartment injections. J Hand Surg Am.
r
Hand surgeons injected the medication and radiologists who were blinded to the surgeons’ technique examined the accuracy on radiographs. Patients were observed for 3 months and follow-up results were recorded by clinicians who were blinded to the radiologists’ interpretation. In this trial, the researchers found that injection of the first dorsal compartment was accurately placed 84% of the time and that marked relief was reported in 57% of patients. Hajder et al23 reported a retrospective, single-arm series of 71 wrists with de Quervain tendinopathy Vol. 39, December 2014
Evidence-Based Medicine
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ULTRASOUND GUIDANCE OF STEROID INJECTIONS
2500
ULTRASOUND GUIDANCE OF STEROID INJECTIONS
Evidence-Based Medicine
injected with corticosteroids under US guidance. A total of 73% of patients experienced relief after one injection, and 91% with a second injection. Compared with averages reported in the literature, the authors thought that US-guided injections were better for the second injection but not the initial one. In a randomized, controlled study of 44 patients with de Quervain tendinopathy, patients were randomized to receive either US-guided or palpationguided injections. Symptoms and disability were recorded electronically by a rheumatologist blinded to the patients’ cohort assignment. Patients receiving USguided injections reported less pain 4 weeks after injection than did patients receiving standard injections.24 Trigger finger In a cadaver study, trigger finger injections were completely contained within the tendon sheath in 70% of US-guided injections compared with 15% of standard injections, and 30% of the standard injections resulted in dye found in the tendon.2,25 In 2009, Bodor and Flossman26 used US-guided corticosteroid injection for trigger finger and reported that 90% had no triggering 6 months after injection and 71% had no triggering 3 years after injection. A retrospective review of 112 patients with trigger thumb treated with US-guided injections evaluated one year later found that 86% had no triggering after one injection.27 MCP and PIP joints In a study of 70 patients, the accuracy of USguided and palpation-guided needle placement in the metacarpophalangeal (MCP) and PIP joints was evaluated by a musculoskeletal ultrasonographer using high-resolution ultrasound.28 The radiographic evaluation was done simultaneously with the procedure (performed by a rheumatologist); however, there was no blinding. Ultrasound-guided injections were accurately placed in 100% of MCP joints and 92.3% of PIP joints. This was significantly better than palpation-guided injections, which were 80% accurate in MCP joints and 50% accurate in PIP joints (P < .05) (Table 1).28 SHORTCOMINGS OF THE EVIDENCE There is no evidence that corticosteroid injection is better than placebo injection for most of these conditions. Studies of US-guided injections are limited largely to uncontrolled cohorts and anatomical studies. Sham US-guided controls and blinding of subjects is notably absent in most studies. There are no cost-benefit analyses. The lack of such studies is J Hand Surg Am.
r
surprising given how common these conditions are. Although overt conflicts of interest were uncommon, the reader should assume that these studies are likely done by enthusiasts and advocates of US and should be aware that many physicians bill for US and profit from it. DIRECTIONS FOR FUTURE RESEARCH Double-blind, placebo-controlled, prospective, randomized trials are needed to determine whether corticosteroid injections are more effective than placebo injections for these hand and wrist conditions. If we can establish that corticosteroid injections are truly palliative or disease-modifying, we can determine the role of US compared with palpation-guided corticosteroid injections for various hand and wrist pathologies using additional randomized trials employing sham US, independent evaluators, and other methods to minimize bias. Dispassionate researchers who do not stand to benefit from the results should conduct these studies. OUR CURRENT CONCEPTS FOR THIS PATIENT We find the potential for US guidance to improve the accuracy of injections of tendon sheaths and small joints appealing. We inform patients about the added cost and our added profit (conflict of interest) associated with US in the setting of limited evidence of improved palliation or disease modification, and allow each patient to make an informed decision. REFERENCES 1. Gilliland CA, Salazar LD, Borchers JR. Ultrasound versus anatomic guidance for intra-articular and periarticular injection: a systematic review. Phys Sportsmed. 2011;39(3):121e131. 2. Lee D-H, Han S-B, Park J-W, Lee S-H, Kim K-W, Jeong W-K. Sonographically guided tendon sheath injections are more accurate than blind injections: implications for trigger finger treatment. J Ultrasound Med. 2011;30(2):197e203. 3. Orlandi D, Corazza A, Silvestri E, et al. Ultrasound-guided procedures around the wrist and hand: how to do. Eur J Radiol. 2014;83(7):1231e1238. 4. Smith J, Brault JS, Rizzo M, Sayeed YA, Finnoff JT. Accuracy of sonographically guided and palpation guided scaphotrapeziotrapezoid joint injections. J Ultrasound Med. 2011;30(11):1509e1515. 5. Grassi W, Farina A, Filippucci E, Cervini C. Sonographically guided procedures in rheumatology. Semin Arthritis Rheum. 2001;30(5): 347e353. 6. Lopes R, Furtado R, Parmigiani L, Rosenfeld A, Fernandes A, Natour J. Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology (Oxford). 2008;47(12):1792e1794. 7. Nam SH, Kim J, Lee JH, Ahn J, Kim YJ, Park Y. Palpation versus ultrasound-guided corticosteroid injections and short-term effect in the distal radioulnar joint disorder: a randomized, prospective singleblinded study. Clin Rheumatol. 2013 Aug 11. [Epub ahead of print]. 8. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided
Vol. 39, December 2014
9.
10. 11.
12.
13.
14.
15.
16.
17.
18.
injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004;31(2):308e314. Üstün N, Tok F, Yagz AE, et al. Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: a single-blind randomized prospective study. Am J Phys Med Rehabil. 2013;92(11):999e1004. Wolf JM. Injections for trapeziometacarpal osteoarthrosis. J Hand Surg Am. 2010;35(6):1007e1009. Dubreuil M, Greger S, LaValley M, Cunnington J, Sibbitt WL Jr, Kissin EY. Improvement in wrist pain with ultrasound-guided glucocorticoid injections: a meta-analysis of individual patient data. Semin Arthritis Rheum. 2013;42(5):492e497. Sibbitt WL Jr, Band PA, Chavez-Chiang NR, Delea SL, Norton HE, Bankhurst AD. A randomized controlled trial of the cost-effectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. J Rheumatol. 2011;38(2):252e263. Sibbitt WL, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36(9):1892e1902. Cunnington J, Marshall N, Hide G, et al. A randomized, doubleblind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum. 2010;62(7):1862e1869. Mandl LA, Hotchkiss RN, Adler RS, Ariola LA, Katz JN. Can the carpometacarpal joint be injected accurately in the office setting? Implications for therapy. J Rheumatol. 2006;33(6):1137e1139. Di Sante L, Cacchio A, Scettri P, Paoloni M, Ioppolo F, Santilli V. Ultrasound-guided procedure for the treatment of trapeziometacarpal osteoarthritis. Clin Rheumatol. 2011;30(9):1195e1200. Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ. 1993;307(6915):1329. Luz K, Furtado R, Nunes C, Rosenfeld A, Fernandes A, Natour J. Ultrasound-guided intra-articular injections in the wrist in patients with rheumatoid arthritis: a double-blind, randomised controlled study. Ann Rheum Dis. 2008;67(8):1198e1200.
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Vol. 39, December 2014
Evidence-Based Medicine
ULTRASOUND GUIDANCE OF STEROID INJECTIONS
