Luca Di Sante

Intramuscular oxygen-ozone therapy in the treatment of acute back pain with lumbar disc herniation: A multicenter, randomized, double-blind, clinical trial of active and simulated lumbar paravertebral injection

Study Design. Multicenter randomized, double-blind, simulated therapy-controlled trial in a cohort of patients with acute low back pain (LBP) due to lumbar disc herniation (LDH). Objective. To assess the benefit of intramuscular-paravertebral injections of an oxygen-ozone (O2O3) mixture. Summary of Background Data. Recent findings have shown that O2O3 therapy can be used to treat LDH that fails to respond to conservative management. However, these findings are based on intradiscal/intraforaminal O2O3 injection, whereas intramuscular-paravertebral injection is the technique used most in clinical practice in Italy and other Western countries. Methods. Sixty patients suffering from acute LBP caused by LDH was randomized to an intramuscular O2O3 or control group. Patients were observed up to assess pain intensity, LBP-related disability, and drug intake (15 [V2] and 30 [V3] days after treatment started, and 2 weeks [V4], and 3 [V5] and 6 [V6] months after treatment ended). Results. A significant difference between the 2 groups in the percentage of cases who had become pain-free (61% vs. 33%, P < 0.05) was observed at V6. Patients who received O2O3 had a lower mean pain score than patients who received simulated therapy throughout the observation period. A significant improvement was observed in LBP-related disability in the study group patients when compared with the control group patients. Active O2O3 therapy was followed by a significantly lower number of days on nonsteroidal anti-inflammatory drugs at V2 and V3 and by a lower number of days at V4. No adverse events were reported. Conclusion. Treatment of LBP and sciatica is a major concern. Although the natural history of acute LBP is often self-limiting, conservative therapies are not always effective; in such cases, O2O3 intramuscular lumbar paravertebral injections, which are minimally invasive, seem to safely and effectively relieve pain, as well as reduce both disability and the intake of analgesic drugs.

Extracorporeal Shock-Wave Therapy for Supraspinatus Calcifying Tendinitis: A Randomized Clinical Trial Comparing Two Different Energy Levels

Background Extracorporeal shock-wave therapy (ESWT) represents a valid intervention in the treatment of people with supraspinatus calcifying tendinitis (SCT), but there is limited evidence for the useful range of ESWT doses. Objective The aim of this study was to compare 2 different ranges of energy flux density in treatment of SCT with ESWT. Design This study was designed as a single-blind randomized clinical trial. Setting This study was performed in a university hospital. Patients Forty-six patients with SCT were randomly assigned to 2 groups that received different therapeutic energy doses of ESWT: (1) group A received ESWT at an energy level of 0.20 mJ/mm2, and (2) group B received ESWT at an energy level of 0.10 mJ/mm2. Intervention The treatment protocol consisted of 4 sessions performed once a week. Measurements The change in mean Constant Murley Scale (CMS) scores at 3 and 6 months was the primary endpoint. The change in the mean visual analog scale (VAS) scores from baseline to 3 and 6 months after the intervention and radiographic change in size of calcium deposits were evaluated as secondary endpoints. At 12 months, pain relief was assessed using a numeric rating scale. Results Significant clinical improvement based on mean CMS scores was observed after 6 months in group A (X̅=79.43, SD=10.33) compared with group B (X̅=57.91, SD=6.53). Likewise, after 6 months, a significant decrease in VAS scores was found in group A (X̅=2.09, SD=1.54) compared with group B (X̅=5.36, SD=0.78). Calcific deposits disappeared in the same percentage of patients in both groups. Limitations The small sample size and lack of a control group were limitations of the study. Conclusions In ESWT for SCT, an energy level of 0.20 mJ/mm2 appears to be more effective than an energy level of 0.10 mJ/mm2 in pain relief and functional improvement.

Ultrasound-guided aspiration and corticosteroid injection of Baker's cysts in knee osteoarthritis: a prospective observational study.

Di Sante L, Paoloni M, Ioppolo F, Dimaggio M, Di Renzo S, Santilli V: Ultrasound-guided aspiration and corticosteroid injection of Bakers cysts in knee osteoarthritis: A prospective observational study. Objective:To determine the effect on pain, function, and ultrasonographic findings of ultrasonography-guided Bakers cyst aspiration followed by corticosteroid injection in a group of patients with Bakers cyst secondary to knee osteoarthritis. Design:Prospective observational study. Results:Twenty-six subjects participated in this study. Clinical and instrumental evaluations were performed at baseline (T0), 1 wk (T1), and 4 wks (T2) after procedure. Mean Visual Analog Scale scores significantly dropped after the procedure (T0 = 6.2 [1.2]; T1 = 4.48 [1.5]; T2 = 4.32 [1.3]; T0 vs. T1 and P < 0.0001). A significant difference between preprocedure and postprocedure Western Ontario and McMaster Universities scores was found for pain (P < 0.0001) but not for joint stiffness (P = 0.7239) and disability (P = 0.6318). Ultrasonographic evaluation showed a significant reduction for both axial (P = 0.006) and sagittal (P = 0.01) areas of Bakers cyst, but no correlation was found between pain relief and Bakers cyst volume reduction. Conclusions:Cyst aspiration with corticosteroid injection give pain relief and cyst volume reduction in patients with Bakers cyst and concomitant knee osteoarthritis. However, when compared with current literature, our results are similar to those obtained with intra-articular knee corticosteroid injection.

Kinematic and kinetic modifications in walking pattern of hip osteoarthritis patients induced by intra-articular injections of hyaluronic acid

BACKGROUND A growing body of evidence points to the efficacy of intra-articular injections of hyaluronic acid, in dealing with pain and function in hip osteoarthritis. To date, however, no data exist as to this treatments effect on walking pattern. METHODS We performed a prospective, open study in order to verify, in a group of 20 hip osteoarthritis patients (12 men, 8 women, mean age 60.5, range 47-73), the clinical effects of 3 intra-articular injections of 2 ml of hyaluronic acid in the hip (1/week) in terms of pain and function at 1 (T1), 3 (T2) and 6-month (T3) follow-ups, as well as changes in the kinematics and kinetics of gait at 6-month follow-up. FINDINGS Pain as measured with visual analog scale significantly dropped after this procedure (P<0.0001). A significant improvement was noted regarding stiffness (P=0.005) and disability (P=0.04), as measured by the Western Ontario and McMaster Universities osteoarthritis index. As regards gait analysis, patients at T3 walked with higher cadence (P=0.004) and stride length (P=0.02) compared to T0. Moreover, a significant increase for the pelvic tilt at heel contact (P=0.0004) and for hip flexion-extension moment at loading response sub-phases of gait cycle (P=0.02) was noted at T3. INTERPRETATION In line with current literature, our patients display clinical improvement 6 months after intra-articular injections of hyaluronic acid, accompanied by changes in walking pattern, as measured by instrumental gait analysis. The kinematic and kinetic changes observed may be the consequence of the therapeutic effect of intra-articular injections of hyaluronic acid.

Re: Ultrasound-guided corticosteroid injection for the treatment of de Quervain's tenosynovitis.

The Author Responds: The authors thank the reviewers for their remarks. For the first point, they are right because in case of inflammation, tendons appear enlarged. There is a typographic error in the quoted sentence of the article: the correct word is Bthickened[ and not Bthinner.[ Indeed, as can be read in the legend of Figure 1, the tendons of the abductor pollicis longus and extensor pollicis brevis muscles appeared Bthickened[ because Bthe tendon sheaths are distended and surrounded by a fluid that gives the appearance of a circumferential hypoechogenicity.[ For the second point, because there is no criterion standard method to inject the tendon’s sheath, the authors believe that the exclusive use of either the in-plane or the out-of-plane technique is not indicated. Both have their advantages and limitations, and the choice depends on the experience of the operator. Although the insertion of the needle parallel to the transducer is considered a good technique, because the entire length of the needle can be seen at all times, the authors believe that limitations can also occur in this approach. Moreover, if the authors want to inject both the abductor pollicis longus and extensor pollicis brevis tendons’ sheath, they have to perform two separate injections, whereas with the needle perpendicular to the transducer, they can inject both tendons’ sheath with only one injection (Figs. 1A, B). From the authors’ experience, with the metal wire technique, there is no risk for intratendinous injection. Indeed, after the wire profile is marked, the needle is inserted perpendicularly to the transducer and is moved forward until the authors are sure that the tip is within the tendon’s sheath and they are injecting only the synovial swelling. The authors believe that their approach is ideal to inject the superficial structures such as, for example, trapeziometacarpal injection. Indeed, in their video, the operator performs a peritendinous synovial injection, a superficial procedure.

17-Italian Foot Function Index with numerical rating scale: development, reliability, and validity of a modified version of the original Foot Function Index.

BACKGROUND Clinical research quantifies symptoms and signs of pain. OBJECTIVE To develop a brief outcome measure to assess foot and ankle conditions, the psychometric properties of a modified version of the original Foot Function Index (FFI) were examined. METHODS Eighty-six subjects with musculoskeletal foot and ankle disorders were enrolled. The internal consistency and test-retest reliability were evaluated by using Cronbachs α and intraclass correlation coefficient (ICC). Criterion validity was tested by Pearsons correlation coefficient between 17 items of the Italian FFI (17-IFFI) and the Lower Extremity Functional Scale (LEFS). The responsiveness was calculated using the receiver operating characteristic curve (ROC). RESULTS Cronbachs Alpha was 0.95 (95% CI: 0.92, 0.99). The intra-interviewer and inter-interviewer ICC values were, respectively, 0.92 (95% CI: 0.88-10 0.96) and 0.90 (95% CI: 0.89-0.94). Correlations between the 17-IFFI scores and the LEFS scores were -0.564 and -0.456 at the initial and at the end of the treatment, respectively. The ROC analysis revealed an area under the curve of 0.732 (95% CI: 0.61-0.82) for the 17-IFFI and 0.633 (95% CI: 0.52-0.71) for the LEFS score. CONCLUSIONS The 17-IFFI is a reliable and valid scale and we recommend its application to evaluate the effectiveness of a treatment in patients with musculoskeletal foot and ankle disorders.

Ultrasound in tarsal tunnel syndrome: Correct diagnosis for appropriate treatment

We have read with interest the study, by Kim and colleagues, entitled “A Case of Lateral Calcaneal Neuropathy: Lateral Heel Pain”, about the utility of ultrasound (US) for diagnosis of entrapment of the lateral calcaneal branch of the sural nerve. They performed US examination in a 29-year-old patient, finding increased crosssectional area (CSA) of the aforementioned nerve branch. The patient had a 3-month history of pain in the lateral heel and was treated with extracorporeal shock wave therapy (ESWT), because plantar fasciitis was suspected. After treatment, sensory impairment occurred. The study is very important and stimulating for different reasons. First, the study shows and confirms the ability of US to find lesions even in very small nerves. This is a crucial point, because US is an extension of the clinical examination and allows depiction of morphological changes in peripheral nerves. We would like to report a similar case, in which ESWT was performed for misdiagnosed tarsal tunnel syndrome, and US was crucial to plan the most appropriate treatment. A 67-year-old man came to our attention from another hospital, because he complained of pain in the right foot plantar region and was suspected to have plantar fasciitis. The patient was treated with 2 cycles of ESWT (3 weekly administrations of 2400 shocks, 0.15 mJ/mm, 4 HZ on the painful region) without benefits. Clinical history and examination revealed burning pain and paresthesia in the anterior part of the right sole. A Tinel sign was evoked on percussion the area behind the right medial malleolus. Bilateral US evaluation at the level of the tarsal tunnel, in the region of the medial malleolus, revealed increased size of the right tibial nerve in comparison with the contralateral side (right CSA, 17 mm, left CSA, 12 mm, see Fig. 1). The right nerve showed a single large and hypoechoic

Groin pain and iliopsoas bursitis: Always a cause-effect relationship?

BACKGROUND AND OBJECTIVE Iliopsoas bursitis (IB) is characterized by inflammation and enlargement of the iliopsoas bursa. Although this condition is often associated with degenerative or inflammatory arthritis, infections, trauma, overuse and impingement syndromes, osteonecrosis and hip replacement, the pathogenesis of IB remains uncertain. We present a case report of IB associated with moderate hip osteoarthritis (HOA). METHODS We present a case report of a 73-year-old man with chronic left hip pain that did not respond to conservative treatments. An ultrasonography examination of the left hip revealed fluid-induced distension of the iliopsoas bursa, which was treated with aspiration followed by a corticosteroid-anesthetic injection. RESULTS At the 30-day follow-up, despite an initial improvement in the patients symptoms, both the pain and functional limitation returned, though not in association with bursa distension. The patient therefore underwent a total hip arthroplasty, which fully relieved the symptoms. CONCLUSION We hypothesize that iliopsoas bursitis may, when associated with other pathological conditions, not be the only source of pain. It should, nevertheless, be considered for differential diagnosis purposes.

Comparison Between Extracorporeal Shock Wave Therapy and Intra-articular Hyaluronic Acid Injections in the Treatment of First Carpometacarpal Joint Osteoarthritis

Objective To compare extracorporeal shockwave therapy (ESWT) with hyaluronic acid (HA) intra-articular injections in terms of pain relief, improvement in hand function, and strength in subjects with first carpometacarpal (CMC) joint osteoarthritis. Methods Fifty-eight patients received either focused ESWT or HA injection once a week for 3 consecutive weeks. In the ESWT group, 2,400 consecutive pulses were performed during each treatment session using a frequency of 4 Hz and an energy flux density of 0.09 mJ/mm2. The HA group underwent one cycle of three injections of 0.5 cm3 HA. The main outcome measures were pain and hand function as measured by the visual analogue scale (VAS) and Duruoz Hand Index (DHI), respectively. The secondary outcomes were grip and pinch strength. Each assessment was performed at baseline, at the end of treatment, and at 3- and 6-month follow-up visits. Results According to VAS and DHI scores, a significant change in test performance was observed over time in both groups (p<0.001), with a greater average improvement in painful symptomatology at the 6-month follow-up in the ESWT group. A significant improvement in strength was observed in both groups, but the ESWT group showed better results on the pinch test starting immediately at the end of treatment. Conclusion The use of ESWT in patients with first CMC joint osteoarthritis leads to a reduction in pain, an improvement in pinch test performance that persists for at least 6 months, and a decrease in hand disability up to the 6-month follow-up visit.