André Rosenfeld

Ultrasound-guided intra-articular injections in the wrist in patients with rheumatoid arthritis: a double-blind, randomised controlled study

Intra-articular (IA) injections with glucocorticoid are a valuable therapeutic intervention for patients with rheumatoid arthritis (RA) and wrist synovitis. Jones et al have demonstrated that half of the wrist blind injections were considered to be extra-articular.1 Musculoskeletal ultrasound (US) allows for the proper real-time allocation of the needle during the injections, limiting the risk of damage to the cartilage, tendons, nerves and peripheral blood vessels.2 In this study we compare the efficacy of blind and US-guided IA injections in patients with RA with wrist synovitis. The accuracy of the techniques used to inject the drug into wrist joint is …

Effect of Facet Joint Injection Versus Systemic Steroids in Low Back Pain: A Randomized Controlled Trial.

Study Design. Randomized clinical trial. Objective. To compare the effectiveness of facet joint injection versus systemic steroid in patients with a diagnosis of facet joint syndrome. Summary of Background Data. The term facet joint syndrome has been used to define back pain originating from the facet joints. Treatment is mainly conservative, although interventions, including intra-articular injections and medial branch nerve blocks are used to manage facet-mediated pain. Several studies have evaluated the effectiveness of these interventions. Results of facet joint injection, however, are conflicting. Methods. Sixty subjects with a diagnosis of facet joint syndrome were enrolled in the study. They were randomized into experimental and control groups. The experimental group was administered with intra-articular injection of 6 lumbar facet joints with triamcinolone hexacetonide; the control group was administered with triamcinolone acetonide intramuscular injection of 6 lumbar paravertebral points. Visits were taken at baseline and at 1, 4, 12, and 24 weeks after interventions. Outcome measures were used: pain visual analogue scale, pain visual analogue scale during extension of the spine, Likert scale, improvement percentage scale, Roland-Morris, 36-Item Short Form Health Survey, and accountability of medications taken. Homogeneity was tested using the Student t, Pearson &khgr;2, and Mann-Whitney tests. Analysis of variance was used to analyze differences in the groups over time and the Student t test to analyze differences between groups at each time evaluation. Results. The groups were similar at baseline. Comparisons between the groups showed, in analysis of variance analysis, an improvement in the experimental group regarding diclofenac intake and quality of life, in the “role physical” profile, assessed by 36-Item Short Form Health Survey. In the analysis at each time point, an improvement in the experimental group was also found in the Roland-Morris questionnaire, in the improvement percentage scale and in the response to treatment, assessed by the Likert scale. Conclusion. Both treatments were effective, with a slight superiority of the intra-articular injection of steroids over intramuscular injection. Level of Evidence: 2

Diagnóstico por imagem do punho na síndrome do túnel do carpo

A síndrome do túnel do carpo (STC) resulta da compressão do nervo mediano no túnel do carpo, sendo a neuropatia mais comum da extremidade superior. O túnel do carpo é um espaço restrito, elíptico, confinado ventralmente pelo retináculo dos flexores, inelástico e resistente e, dorsalmente, pela superfície anterior dos ossos do carpo. As maiores estruturas que passam pelo túnel são: quatro tendões flexores superficiais dos dedos e quatro tendões flexores profundos, tendão do flexor longo do polegar, e o nervo mediano. A incidência de STC na população geral é menor do que 1%, podendo ser encontrados, entretanto, valores acima de 15% em trabalhadores de risco, sendo a tendinite o achado mais comum. A compressão da STC é causada pela discrepância entre a capacidade rígida do canal e o volume de seu conteúdo. Dado que o volume do conteúdo e a capacidade do canal variam com a posição do punho em relação ao eixo do antebraço, os períodos de compressão podem ser inconstantes, e os sintomas resultantes tendem a flutuar (Tabela 1). A STC ocupacional é causa de absenteísmo no trabalho e de disputas legais. Como a incidência de STC continua a aumentar, a avaliação acurada desses pacientes torna-se de fundamental importância.

Efetividade da infiltração intra-articular guiada por imagem: comparação entre fluoroscopia e ultrassom

OBJECTIVE Compare the effectiveness of ultrasound and fluoroscopy to guide intra-articular injections (IAI) in selected cases. MATERIAL AND METHODS A prospective study in our outpatient clinics at the Rheumatology Division at Universidade Federal de São Paulo (UNIFESP), Brazil, was conducted to compare the short-term (4 weeks) effectiveness of ultrasound and fluoroscopy-guided IAI in patients with rheumatic diseases. Inclusion criteria were: adults with refractory synovitis undergoing IAI with glucocorticoid. All patients had IAI performed with triamcinolone hexacetonide (20mg/ml) with varying doses according to the joint injected. RESULTS A total of 71 rheumatic patients were evaluated (52 women, 44 whites). Mean age was 51.9 ± 13 years and 47 of them (66.2%) were on regular DMARD use. Analysis of the whole sample (71 patients) and hip sub-analysis (23 patients) showed that significant improvement was observed for both groups in terms of pain (P < 0.001). Global analysis also demonstrated better outcomes for patients in the FCG in terms of joint flexion (P < 0.001) and percentage change in joint flexion as compared to the USG. Likert scale score analyses demonstrated better results for the patients in the USG as compared to the FCG at the end of the study (P < 0.05). No statistically significant difference between groups was observed for any other study variable. DISCUSSION AND CONCLUSION Imaging-guided IAI improves regional pain in patients with various types of synovitis in the short term. For the vast majority of variables, no significant difference in terms of effectiveness was observed between fluoroscopy and ultrasound guided IAI.

Avaliação por imagem das lesões da placa de crescimento

The structures responsible for the growth of bones include the physis (also called growth plate) and the epiphysis. Affections involving patients with immature skeletons, i.e., with a still open growth plate, may affect the bone growth, resulting in complications such as growth arrest, limb shortening and angular deformities. Traumatic conditions, many times resulting in epiphyseal fractures, are the most frequent cause of growth plate injuries. A careful evaluation of these patients by means of currently available imaging methods, especially radiography, computed tomography and magnetic resonance imaging, allows an early diagnosis of the involvement of structures related to the bone growth, besides an appropriate management, reducing the probability of secondary complications.

A importância dos exames de imagem no diagnóstico da pubalgia no atleta

239 A pubalgia e um problema relativamente comum em atletas, acometendo cerca de 5% deste grupo de profissionais(1). Tal entidade afeta principalmente praticantes de esportes nos quais sejam necessarios chutes repetitivos e mudancas bruscas de direcao do movimento, particularmente no rugbi, hoquei, tenis e futebol(1). Em geral, a queixa e insidiosa, notando-se piora gradativa e exacerbacao dos sintomas quando sao realizados movimentos especificos de chute, rotacao ou aducao da coxa. O diagnostico diferencial de pubalgia e amplo, incluindo, entre outras, doencas intra-articulares do quadril – como a rotura labral, sacroiliite –, hernia de disco lombar, bursite do iliopsoas, doencas da cavidade pelvica – como cistos de ovario e hernias inguinais(2). Porem, neste especifico grupo de pacientes, deve-se considerar inicialmente no diagnostico diferencial osteite pubica, disfuncao dos adutores (incluindo rotura do tendao conjunto) e rotura da aponeurose do obliquo externo e reto abdominal(1,3). A diferenciacao clinica e subsequente tratamento podem ser dificeis por causa da sobreposicao dos sintomas, complexa anatomia local, achados ao exame fisico e multiplas possibilidades de diagnostico diferencial(1,3). Em virtude de tais fatos, os exames de imagem sao importante auxilio no estabelecimento do diagnostico, visto que a ressonância magnetica (RM) apresenta sensibilidade de 98% e especificidade de 89% a 100% em pacientes com pubalgia(4).

THU0352 Blinded VS Ultrasound-Guided Corticosteroid Injections for the Treatment of the Greater Trochanteric Pain Syndrome (SDPT): A Randomized Controlled Trial

Background The peritrochanteric corticosteroid injections with anesthesics is one of the suggested treatments for the refractory case of the Greater Throcanteric Pain Syndrome and this therapeutic intervention can be guided or not. Objectives To compare the effectiveness of both injections in the Greater Trochanteric Pain syndrome treatment: The blinded corticosteroid injections and the ultrasound-guided corticosteroid injections. Methods A prospective, randomised, double – blind, controlled study was made involving 60 patients (from 19 – 65 years old) who were diagnosed with GTPS for at least 30 days. The patients were randomised in two groups. Both groups were infiltraded once. Group 1 (n=30) was infiltraded blindly. Group 2 (n=30) was infiltrated with the ultrasound guidance. In both groups betamethasone (6 mg) and lidocaine (2 cc) were used in a same syringe. Two blinded observers evaluated the experiment during week 0, 1, 4 and 8 after the procedure, using a visual analogue scale (VAS: 0-10). The patients were followed according: Spontaneous pain, painfull palpation, global health, external rotation pain, pain when testing against resistance, repositioning functional testing, “time up and go” (time in minutes), test six-minute walk (distance in meters), Lequesne hip; goniometry hip (flexion, extension and abduction), and ultrasound qualitative and quantitative (in mm) measurements of the gluteus medium tendon, minimum tendon and trochanteric bursa. Side effects were observed and evaluated during the research. Results We studied 60 patients with a mean age of 54 years (10.1), mean duration of pain peritrochanteric of 32.2 months (35.8), with 98% of women, 90% white and 61.66% sedentary. After 8 weeks of follow-up, there was improvement over the initial time (intra-group evaluation) in both groups. Using repeated measures ANOVA, there was no significant difference between the groups for local pain VAS (p=0.347), VAS of pain on palpation (p=0.873), EVA external rotation (p=0.215), test repositioning against resistance (p=0.855), test “time up and go” (p=0.062), test the six-minute walk (p=0.537), Lequesne hip (p=0.802). There was also no statistical difference in the sonographic assessment (p>0.1). The variable VAS global health, was the only one that evolved differently between groups over time (p=0.023) with better intergroup evaluation for group 2. There were no significant adverse effects. Conclusions There are benefits when it comes to the patients general perception, but according to this study, there is no benefit (intermediate-term) when ultrasound-guided infiltration is used in GTPS patients. References Cohen SP, Strassels SA, Foster L, et al. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomized controlled trial. BMJ 2009; 338:b1088 Labrosse JM, Cardinal E, Leduc BE, et al. Effectiveness of ultrasound-guided corticosteroid injection for the treatment of gluteus medius tendinopathy. AJR 2010; 194:202–206 Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc 1996; 71:565–569 Ege Rasmussen KJ, Fanø N. Trochanteric bursitis: treatment by corticosteroid injection. Scand J Rheumatol 1985; 14:417–420 Acknowledgements Ultrasound-guided; corticosteroid injections; Greater Trochanteric Pain Syndrome. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.5394

Avaliação por imagem dos elastofibromas da cintura escapular

Elastofibroma dorsi, a slow-growing, soft-tissue pseudotumor has been more and more remembered in the differential diagnosis of chronic scapular pain. It has also been incidentally diagnosed in routine diagnostic imaging tests. Our approach here is the imaging diagnosis, which can start with the conventional X-ray, but is better characterized by the ultrasound and the magnetic resonance, the latter being the modality of choice.

Raízes meniscais: anatomia e avaliação por meio da ressonância magnética

As raizes anteriores e posteriores sao os componentes meniscais que fixam os meniscos nos platos tibiais proximo a insercao dos ligamentos cruzados (Figura 1). As raizes, tambem chamadas de enteses, sao estruturas criticas para a funcao biomecânica dos meniscos, porque lesoes dessa regiao, assim como lesoes radiais extensas e lesoes complexas, interrompem as fibras de colageno circunferenciais e determinam uma expansao radial do menisco, com subluxacao e extrusao deste. Assim, forcas axiais compressivas sao transmitidas diretamente para a cartilagem articular, o que leva a degeneracao precoce da cartilagem e a osteoartrose(1,2). O reconhecimento de lesoes meniscais comprometendo essas estruturas tem, portanto, relevância clinica, pois seu diagnostico propicia formas mais adequadas de tratamento, evitando progressao das lesoes meniscais e das alteracoes degenerativas articulares.

AB0755 Entheses ultrasound in patients with ankyosing spondylitis: a controlled study with healthy subjects.

Background Inflammation of the entheses (enthesitis) is a characteristic finding of ankylosing spondylitis (AS). Despite the growing interest in rheumatology for musculoskeletal ultrasound (US), there are not many studies evaluating the entheses in AS through the US. Objectives To compare US findings of entheses between AS patients and healthy subjects; To assess entheses by US and correlate with clinical, functional and inflammatory aspects in patients with AS Methods We conducted a cross sectional study of 50 patients with AS and 30 healthy volunteer subjects matched for age and sex. Were evaluated by US the following entheses: brachial triceps, femoris quadriceps, proximal patellar tendon, distal patellar tendon, calcaneal tendon, and plantar fascia. The clinical evaluation of patients included a global health scale, visual analogue scale (VAS) for pain and swollen, calculation of BASDAI, BASFI, BASMI, HAQ-S, ASDAS-VHS and enthesitis index SPARCC (Spondyloarthritis Research Consortium of Canada Enthesitis Index). The US exam was performed at right and left entheses of samples by a radiologist expert in musculoskeletal “blind” to clinical findings and based on MASEI index (Madrid Sonographic Enthesis Index) and the analysis of its sub items (bursistis, calcification, erosion, power doppler, thicknening of tendon, structural change). For evaluation was used the Esaote MyLab60 machine equipped with a linear transducer with a frequency of 6-18 MHz. Results Were evaluated by US 960 entheses of total sample of 63 men (78,75%) and 17 women (21,25%). The patients had mean age of 43,44 (± 9,91) years and healthy subjects 38,7 (±8,52) years. The mean disease duration was 11,11 (± 6,77) years. The comparison of average MASEI total score between patient and control groups (16,32 + 11,11 / 10,70 + 5,27) was not statistically different (p = 0,519). There was a statistical difference between groups for the detection of erosion (17 patients/0 healthy; p= 0,00) and power Doppler (PD) in calcaneal entheses (6 patients/0 healthy; p= 0,053) and for erosion (7/0; p=0,037) and thickening of the plantar fascia (38/9 p = 0,002). The latter showed an odds ratio of 3,47 (p = 0,03) of belonging to AS group, according to logistic regression. There was no difference between groups for ultrasound evaluation of other entheses. Correlation of entheses US findings and clinical, functional, inflammatory aspects was weak. However, the PD of the calcaneal entheses was correlated with VAS pain (0,344 p= 0,00) and VAS swollen (0,486 p = 0,00). The VAS pain and VAS for swollen of the calcaneal entheses correlated statistically (0,653 p = 0,00). Conclusions At ultrasound, the entheses of the feet were the only ones able to differentiate AS patients from healthy subjects. This difference was mainly due to bone erosion in both the calcaneal tendon, as in plantar fascia. The PD on the calcaneal entheses was the only parameter on US that correlates with clinical variables. References E de Miguel, T Cobo, S Muñoz-Fernández et al. Validity of enthesis ultrasound assessment in spondyloarthropathies. Ann Rheum Dis 2009;68;169-174 Disclosure of Interest None Declared