Faculty Bibliography

Objective: The present randomized controlled study addressed whether sonographic needle guidance affected the outcomes of intraarticular injection for osteoarthritis of the knee. Methods: 94 non-effusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed RPD (the reciprocating procedure device) syringe. A one needle, two-syringe technique was used. After intraarticular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intraarticular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined. (Figure Presented) (Figure Presented) Results: Relative to conventional palpation-guided methods, sonographic guidance for injection of the knee resulted in 47.7% reduction in procedural pain (p<0.001), a 41.7% reduction in pain scores at outcome (p<0.03), 107% increase in the responder rate (p<0.001), 51.6% reduction in the non-responder rate (p<0.001), a 35.5% increase in therapeutic duration (p =0.01), a 14.6% reduction ($48) in cost/patient/year, and a 58.8% ($593) reduction in cost/responder/year for a hospital outpatient (p<0.001). Conclusions: Sonographic needle guidance improves the performance, clinical outcomes, and cost-effectiveness of intraarticular injections of the osteoarthritic knee

Platelet-rich plasma is defined as autologous blood with a concentration of platelets above baseline values. Platelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s; its use in sports medicine is growing given its potential to enhance muscle and tendon healing. In vitro studies suggest that growth factors released by platelets recruit reparative cells and may augment soft-tissue repair. Although minimal clinical evidence is currently available, the use of platelet-rich plasma has increased, given its safety as well as the availability of new devices for outpatient preparation and delivery. Its use in surgery to augment rotator cuff and Achilles tendon repair has also been reported. As the marketing of platelet-rich plasma increases, orthopaedic surgeons must be informed regarding the available preparation devices and their differences. Many controlled clinical trials are under way, but clinical use should be approached cautiously until high-level clinical evidence supporting platelet-rich plasma efficacy is available

OBJECTIVE: This randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular (IA) joint injections. METHODS: In total, 148 painful joints were randomized to IA triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating device). A one-needle, 2-syringe technique was used, where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the IA space with lidocaine. After IA placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks), and changes in pain scores were measured with a 0-10 cm visual analog pain scale (VAS). RESULTS: Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p < 0.001), 58.5% reduction in absolute pain scores at the 2 week outcome (p < 0.001), 75% reduction in significant pain (VAS pain score > or = 5 cm; p < 0.001), 25.6% increase in the responder rate (reduction in VAS score > or = 50% from baseline; p < 0.01), and 62.0% reduction in the nonresponder rate (reduction in VAS score < 50% from baseline; p < 0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%. CONCLUSION: Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinically significant manner.

Inter-alpha-inhibitor, TSG-6, and hyaluronan have important functions in fertility and inflammation. Two subunits of inter-alpha-inhibitor, the heavy chains, form covalent bonds with TSG-6 or hyaluronan in vitro. TSG-6-heavy chain complexes serve as intermediates in the transfer of heavy chains from inter-alpha-inhibitor to hyaluronan. In vivo, in addition to these complexes, stable ternary complexes of hyaluronan with both TSG-6 and heavy chains have been demonstrated in the ovulatory cumulus oophorus. In our ongoing efforts to characterize the multiple interactions between hyaluronan, TSG-6 and inter-alpha-inhibitor, we recently characterized the formation of highly stable complexes of TSG-6 with hyaluronan that had been tethered to a solid surface. Here we show that these hyaluronan-TSG-6 complexes are functionally active and transfer heavy chain subunits from inter-alpha-inhibitor to either free or surface-bound hyaluronan. Transitional hyaluronan-TSG-6-heavy chain complexes do not accumulate in vitro. Our data show the capability for heavy chain transfer by both free TSG-6 and preformed hyaluronan-TSG-6 complexes, suggesting that both might contribute to hyaluronan modification in vivo. Transfer of heavy chains to surface-tethered hyaluronan by either free TSG-6 or surface-tethered hyaluronan-TSG-6 complexes did not affect the CD 44-mediated binding of BW 5147 cells in vitro. We show how TSG-6 and hyaluronan together can deplete inter-alpha-inhibitor and generate bikunin, as has been observed in sepsis, and discuss the role of TSG-6 in the generation of hyaluronan-heavy chain complexes associated with ovulation, arthritis, and sepsis

Purpose: The present randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular joint injections. Method: 148 painful joints were randomized (NCT 00651625) to intraarticular triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating procedure device). A one needle, two syringe technique was used where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the intraarticular space. After intraarticular placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling intraarticular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), and changes in pain scores were measured with the 0-10 cm Visual Analogue Pain Scale (VAS). Results: Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p<0.001), a 58.5% and 22.6% further reduction in absolute pain scores at the 2 week and 6 months outcome respectively (p<0.01), a 75% reduction in significant pain (VAS pain score >= 5 cm) (p<0.001), (p<0.01), 62.0% reduction in the non-responder rate (reduction in VAS score < 50% from baseline) (p <0.01), and an increase in duration of therapeutic effect by 22.1% (p <0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%. Conclusion: Sonographic needle guidance significantly improves the performance and outcomes of outpatient intraarticular injections in a clinically significant manner

Purpose: True intraarticular positioning of the needle tip is considered important for outcome of intraarticular injections; however, there are few studies demonstrating that technologies that improve needle positioning actually improve injection. The present pilot study investigated whether devices that facilitate accurate placement of the needle affect the outcomes of intraarticular injections of the osteoarthritic knee. Method: 128 subjects with primary osteoarthritis of the knee were randomized to intraarticular corticosteroid injection (triamcinolone acetonide) with standard syringe or the reciprocating procedure device (RPD), a new safety procedure syringe. Primary outcome measures included baseline pain, procedural pain, and pain at outcome (2 weeks post-injection and 6 months post-injection) as measured by the 0 to 10 cm Visual Analogue Pain Scale (VAS) and well as secondary outcome measures. Results: Significant reductions in pain scores following intraarticular injection occurred with both devices at 2 weeks (Syringe: 63.7+/-38.2% VAS reduction from baseline, p < 0.0001; RPD: 80.0+/-30.4%, p < 0.0001) and 6 months (Syringe: 16.7+/-49.4% VAS reduction from baseline, p < 0.004; RPD: 30.5+/-58.8%, p < 0.0001). However, relative to the conventional syringe, the RPD procedure syringe provided a 37.2% greater reduction in procedural pain (p = 0.005), a 53.8 percent reduction in significant procedural pain (VAS >= 5 cm) (p = 0.016), and a 109.7% increase in aspirated fluid volume. At the 2 week outcome, relative the conventional syringe, the RPD group demonstrated 43.1% less joint pain (RPD VAS: 1.40+/-2 cm.11, Syringe VAS: 2.46+/-2.48, p = 0.04), a 25.6% greater reduction in VAS score from baseline (RPD: 80.0+/-30.4%, Syringe VAS: 63.7+/-38.2%, p = 0.025), 76.4% more asymptomatic individuals (VAS <= 1 cm) (RPD: 65.1% (41/63); Syringe: 36.9% (24/65), p = 0.005), 26.7% fewer non-responders (VAS >= 2 cm) (RPD: 34.9% (22/63); Syringe: 47.6% (31/65), p = 0.005), and a longer duration of therapeutic effect (RPD: 4.43+/-2.00 months, Syringe: 3.16+/-2.18 months, p = 0.006). As expected pain scores at the 6 month outcome were not significantly different between the two syringe treatment groups (p = 0.11). Conclusion: The present study demonstrates that intraarticular injection technologies that permit more accurate placement of the procedure needle significantly improve the outcomes of intraarticular injections for osteoarthritis of the knee