Emanuela Spanò

Ultrasound-Guided Injection of a Corticosteroid and Hyaluronic Acid A Potential New Approach to the Treatment of Trigger Finger

AbstractBackground and Objectives: Stenosing tenosynovitis (trigger finger) is one of the most common causes of pain and disability in the hand, which may often require treatment with anti-inflammatory drugs, corticosteroid injection, or open surgery. However, there is still large room for improvement in the treatment of this condition by corticosteroid injection. The mechanical, viscoelastic, and antinociceptive properties of hyaluronic acid may potentially support the use of this molecule in association with corticosteroids for the treatment of trigger finger. This study examines the feasibility and safety of ultrasound-guided injection of a corticosteroid and hyaluronic acid compared, for the first time, with open surgery for the treatment of trigger finger. Methods: This was a monocentric, open-label, randomized study. Consecutive patients aged between 35 and 70 years with ultrasound-confirmed diagnosis of trigger finger were included. Patients were randomly assigned to either ultrasound-guided injection of methylprednisolone acetate 40 mg/mL with 0.8mL lidocaine into the flexor sheath plus injection of 1mL hyaluronic acid 0.8% 10 days later (n = 15; group A), or to open surgical release of the first annular pulley (n = 15; group B). Clinical assessment of the digital articular chain was conducted prior to treatment and after 6 weeks, and 3, 6, and 12 months. The duration of abstention from work and/or sports activity, and any treatment complications or additional treatment requirements (e.g. physiotherapy, compression, medication) were also recorded. Results: Fourteen patients (93.3%) in group A had complete symptom resolution at 6 months, which persisted for 12 months in 11 patients (73.3%), while three patients experienced recurrences and one experienced no symptom improvements. No patients in group A reported major or minor complications during or after corticosteroid injection, or required a compression bandage. All 15 patients in group B achieved complete resolution of articular impairment by 3 weeks after surgery, but ten patients were assigned to physiotherapy and local and/or oral analgesics for complete resolution of symptoms, which was approximately 30–40 days postsurgery. The mean duration of abstention from work and/or sport was 2–3 days in group A and 26 days in group B. Conclusions: Although the limited sample size did not allow any statistical comparison between treatment groups, and therefore all the findings should be regarded as preliminary, the results of this explorative study suggest that ultrasound-guided injection of a corticosteroid and hyaluronic acid could be a safe and feasible approach for the treatment of trigger finger. It is also associated with a shorter recovery time than open surgery, which leads to a reduced abstention from sports and, in particular, work activities, and therefore may have some pharmacoeconomic implications, which may be further explored. In light of the promising results obtained in this investigation, further studies comparing ultrasound-guided injection of corticosteroid plus hyaluronic acid with corticosteroid alone are recommended in order to clarify the actual benefits attributable to hyaluronic acid.

Ultrasound-guided injection of a corticosteroid and hyaluronic acid: A potential new approach to the treatment of trigger finger

AbstractBackground and Objectives: Stenosing tenosynovitis (trigger finger) is one of the most common causes of pain and disability in the hand, which may often require treatment with anti-inflammatory drugs, corticosteroid injection, or open surgery. However, there is still large room for improvement in the treatment of this condition by corticosteroid injection. The mechanical, viscoelastic, and antinociceptive properties of hyaluronic acid may potentially support the use of this molecule in association with corticosteroids for the treatment of trigger finger. This study examines the feasibility and safety of ultrasound-guided injection of a corticosteroid and hyaluronic acid compared, for the first time, with open surgery for the treatment of trigger finger. Methods: This was a monocentric, open-label, randomized study. Consecutive patients aged between 35 and 70 years with ultrasound-confirmed diagnosis of trigger finger were included. Patients were randomly assigned to either ultrasound-guided injection of methylprednisolone acetate 40 mg/mL with 0.8mL lidocaine into the flexor sheath plus injection of 1mL hyaluronic acid 0.8% 10 days later (n = 15; group A), or to open surgical release of the first annular pulley (n = 15; group B). Clinical assessment of the digital articular chain was conducted prior to treatment and after 6 weeks, and 3, 6, and 12 months. The duration of abstention from work and/or sports activity, and any treatment complications or additional treatment requirements (e.g. physiotherapy, compression, medication) were also recorded. Results: Fourteen patients (93.3%) in group A had complete symptom resolution at 6 months, which persisted for 12 months in 11 patients (73.3%), while three patients experienced recurrences and one experienced no symptom improvements. No patients in group A reported major or minor complications during or after corticosteroid injection, or required a compression bandage. All 15 patients in group B achieved complete resolution of articular impairment by 3 weeks after surgery, but ten patients were assigned to physiotherapy and local and/or oral analgesics for complete resolution of symptoms, which was approximately 30–40 days postsurgery. The mean duration of abstention from work and/or sport was 2–3 days in group A and 26 days in group B. Conclusions: Although the limited sample size did not allow any statistical comparison between treatment groups, and therefore all the findings should be regarded as preliminary, the results of this explorative study suggest that ultrasound-guided injection of a corticosteroid and hyaluronic acid could be a safe and feasible approach for the treatment of trigger finger. It is also associated with a shorter recovery time than open surgery, which leads to a reduced abstention from sports and, in particular, work activities, and therefore may have some pharmacoeconomic implications, which may be further explored. In light of the promising results obtained in this investigation, further studies comparing ultrasound-guided injection of corticosteroid plus hyaluronic acid with corticosteroid alone are recommended in order to clarify the actual benefits attributable to hyaluronic acid.

MR-arthrography in superior instability of the shoulder: correlation with arthroscopy

PurposeThis study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability.Materials and methodsForty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings.ResultsWe detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients.ConclusionsSuperior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.RiassuntoObiettivoScopo del presente lavoro è stato valutare il ruolo dell’artro-risonanza magnetica (RM) nell’identificazione e nella classificazione delle lesioni che possono essere alla base dell’instabilità superiore di spalla.Materiali e metodiQuarantadue pazienti consecutivi con segni clinici di instabilità superiore cronica di spalla sono stati sottoposti ad artro-RM e successiva artroscopia chirurgica. Per ogni paziente abbiamo retrospettivamente considerato i reperti artro-RM e i reperti artroscopici.RisultatiAbbiamo riscontrato 31 lesioni del labbro glenoideo superiore da anteriore a posteriore (SLAP lesions), tutte confermate all’esame artroscopico con 3 casi di sottostima del grado di lesione: nella individuazione delle SLAP lesions la sensibilità, specificità, accuratezza, valore predittivo positivo (VPP) e valore predittivo negativo (VPN) dell’artro-RM sono risultati del 100%; nella valutazione del tipo di SLAP lesion la sensibilità è stata del 100%, la specificità del 78,5%, l’accuratezza del 92,8%, il VPP del 71,7% e il VPN del 100%. Tutti i casi di lassità capsulo-legamentosa (13/42) e di lesione del tendine del capo lungo del bicipite (3/42) sono stati confermati all’artroscopia con sensibilità, specificità, accuratezza, VPP e VPN del 100%. Delle 11 lesioni dei tendini della cuffia dei rotatori diagnosticate con artro-RM, 10 sono state confermate artroscopicamente con sensibilità del 100%, specificità del 96,8%, accuratezza del 97,6%, VPP del 90,9% e VPN del 100%. Lesioni associate sono state diagnosticate in 38/42 pazienti.ConclusioniL’instabilità superiore di spalla è frequentemente associata a condizioni patologiche, come le SLAP lesions o a varianti anatomiche. Il ruolo dell’artro-RM è quello di valutare le caratteristiche delle lesioni della porzione sovraequatoriale della spalla, descrivendone la sede, la morfologia e l’estensione e di identificare e descrivere la presenza di lesioni e varianti anatomiche associate.

Plasma-mediated radiofrequency ablation followed by percutaneous cementoplasty under fluoro-CT guidance: a case report

We report a case of a 81-year-old Caucasian man with colorectal carcinoma, treated by surgery in 1998, referred for palliative treatment of a refractory painful caused by osteolytic metastases of 2.5 cm in back-upper ilium spine. Plasma-mediated radiofrequency ablation was performed under conscious sedation, using Fluoroscopic Computer Tomography guidance. After completing the ablation phase of the procedure, a mixture of bone cement and Biotrace sterile barium sulfate was injected into the ablated cavity.Patient was evaluated by using the Brief Pain Inventory and considering pain interference with daily living at day 1 and 3 and week 1, 2, 3, 4 by means of a telephone interview. A post-procedure Computer Tomography scan was performed to examine the distribution of cement deposition few minutes after the procedure. The plasma mediated RFA and cementoplasty were well tolerated by the patient who did not develop any complication.

The role of MDCT arthrography in the follow-up of scapholunate stabilisation

PurposeThe aim of this study was to assess outcomes in a group of patients with scapholunate dissociation treated with stabilisation surgery (Brunelli-Stanley) and to compare arthrography with multidetector computed tomography (MDCT) with conventional radiography, the gold standard in the follow-up of wrist surgery.Materials and methodsTwelve patients (13 wrists) underwent surgery for scapholunate dissociation and were followed up with clinical (visual analogue scale, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Disabilities of the Arm, Shoulder, and Hand) and radiological assessment (conventional radiography and CT arthrography). Conventional radiography was assessed for: the scapholunate gap, scapholunate angle, radiolunate angle, capitate-lunate angle, and carpal height index; the CT arthrography images were also evaluated for: the distance between the dorsal exit hole of the bone tunnel and the proximal scaphoid pole, the thickness and tension of the flexor carpi radialis (FCR) strip, and any signs of joint degeneration.ResultsAnalysis of the data from conventional radiography and MDCT arthrography demonstrated a significant statistical correlation among the measurements obtained on the radiograms and multiplanar CT reconstructions and the patients’ clinical outcome.ConclusionsOur results show that MDCT arthrography has the same value as conventional radiography in the evaluation of standard parameters (scapholunate gap, scapholunate angle, radiolunate angle, capitolunate angle, carpal height index), but in addition provides an accurate delineation of the FCR tendon graft, allowing differentiation of its thickness, direction and degree of tension.RiassuntoObiettivoScopo del presente lavoro è valutare l’outcome di un gruppo di pazienti affetti da dissociazione scafolunata (DSL) sottoposti a intervento chirurgico di stabilizzazione (Brunelli-Stanley) e descrivere il ruolo dell’artrografia-TC (artro-TC) confrontandola con la radiografia, gold standard nel follow-up del polso operato.Materiali e metodiDodici pazienti (13 polsi) operati per stabilizzazione in DSL; follow-up a 47,2 mesi mediante valutazione clinica (Visual Analogue Scale — VAS, Mayo Wrist Score, Patient-Rated Wrist Evaluation — PRWE e Disabilities of the Arm, Shoulder and Hand scale — DASH) e radiologica (Rx e artro-TC). I criteri radiografici analizzati sono stati: l’intervallo scafo-lunato, l’angolo scafo-lunato, l’angolo radio-lunato, l’angolo capitolunato e l’indice di altezza del carpo. L’artro-TC ha inoltre valutato la distanza tra il foro di uscita dorsale del tunnel osseo e il polo prossimale dello scafoide, lo spessore, l’integrità e il grado di tensione del neolegamento e i segni di degenerazione articolare.RisultatiL’analisi dei reperti radiografici e dell’artro-TC hanno dimostrato una correlazione statisticamente significativa tra le misurazioni prese sulla radiografia convenzionale e sulle ricostruzioni multiplanari (MPR) e l’outcome clinico dei pazienti.ConclusioniI nostri risultati mostrano che l’artro-TC ha lo stesso valore della radiografia nella valutazione dei parametri standard (intervallo scafo-lunato, angolo scafolunato, angolo capitato lunato, angolo radio-lunato, indice di altezza carpale) e consente inoltre l’identificazione del neolegamento permettendo la differenziazione di spessore, direzione e grado di tensione.

Artro-RM di spalla nella instabilità superiore: correlazione con artroscopia

PurposeThis study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability.Materials and methodsForty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings.ResultsWe detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients.ConclusionsSuperior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.RiassuntoObiettivoScopo del presente lavoro è stato valutare il ruolo dell’artro-risonanza magnetica (RM) nell’identificazione e nella classificazione delle lesioni che possono essere alla base dell’instabilità superiore di spalla.Materiali e metodiQuarantadue pazienti consecutivi con segni clinici di instabilità superiore cronica di spalla sono stati sottoposti ad artro-RM e successiva artroscopia chirurgica. Per ogni paziente abbiamo retrospettivamente considerato i reperti artro-RM e i reperti artroscopici.RisultatiAbbiamo riscontrato 31 lesioni del labbro glenoideo superiore da anteriore a posteriore (SLAP lesions), tutte confermate all’esame artroscopico con 3 casi di sottostima del grado di lesione: nella individuazione delle SLAP lesions la sensibilità, specificità, accuratezza, valore predittivo positivo (VPP) e valore predittivo negativo (VPN) dell’artro-RM sono risultati del 100%; nella valutazione del tipo di SLAP lesion la sensibilità è stata del 100%, la specificità del 78,5%, l’accuratezza del 92,8%, il VPP del 71,7% e il VPN del 100%. Tutti i casi di lassità capsulo-legamentosa (13/42) e di lesione del tendine del capo lungo del bicipite (3/42) sono stati confermati all’artroscopia con sensibilità, specificità, accuratezza, VPP e VPN del 100%. Delle 11 lesioni dei tendini della cuffia dei rotatori diagnosticate con artro-RM, 10 sono state confermate artroscopicamente con sensibilità del 100%, specificità del 96,8%, accuratezza del 97,6%, VPP del 90,9% e VPN del 100%. Lesioni associate sono state diagnosticate in 38/42 pazienti.ConclusioniL’instabilità superiore di spalla è frequentemente associata a condizioni patologiche, come le SLAP lesions o a varianti anatomiche. Il ruolo dell’artro-RM è quello di valutare le caratteristiche delle lesioni della porzione sovraequatoriale della spalla, descrivendone la sede, la morfologia e l’estensione e di identificare e descrivere la presenza di lesioni e varianti anatomiche associate.

MR-arthrography in superior instability of the shoulder: correlation with arthroscopy@@@Artro-RM di spalla nella instabilità superiore: correlazione con artroscopia

PurposeThis study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability.Materials and methodsForty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings.ResultsWe detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients.ConclusionsSuperior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.RiassuntoObiettivoScopo del presente lavoro è stato valutare il ruolo dell’artro-risonanza magnetica (RM) nell’identificazione e nella classificazione delle lesioni che possono essere alla base dell’instabilità superiore di spalla.Materiali e metodiQuarantadue pazienti consecutivi con segni clinici di instabilità superiore cronica di spalla sono stati sottoposti ad artro-RM e successiva artroscopia chirurgica. Per ogni paziente abbiamo retrospettivamente considerato i reperti artro-RM e i reperti artroscopici.RisultatiAbbiamo riscontrato 31 lesioni del labbro glenoideo superiore da anteriore a posteriore (SLAP lesions), tutte confermate all’esame artroscopico con 3 casi di sottostima del grado di lesione: nella individuazione delle SLAP lesions la sensibilità, specificità, accuratezza, valore predittivo positivo (VPP) e valore predittivo negativo (VPN) dell’artro-RM sono risultati del 100%; nella valutazione del tipo di SLAP lesion la sensibilità è stata del 100%, la specificità del 78,5%, l’accuratezza del 92,8%, il VPP del 71,7% e il VPN del 100%. Tutti i casi di lassità capsulo-legamentosa (13/42) e di lesione del tendine del capo lungo del bicipite (3/42) sono stati confermati all’artroscopia con sensibilità, specificità, accuratezza, VPP e VPN del 100%. Delle 11 lesioni dei tendini della cuffia dei rotatori diagnosticate con artro-RM, 10 sono state confermate artroscopicamente con sensibilità del 100%, specificità del 96,8%, accuratezza del 97,6%, VPP del 90,9% e VPN del 100%. Lesioni associate sono state diagnosticate in 38/42 pazienti.ConclusioniL’instabilità superiore di spalla è frequentemente associata a condizioni patologiche, come le SLAP lesions o a varianti anatomiche. Il ruolo dell’artro-RM è quello di valutare le caratteristiche delle lesioni della porzione sovraequatoriale della spalla, descrivendone la sede, la morfologia e l’estensione e di identificare e descrivere la presenza di lesioni e varianti anatomiche associate.