Treatment of De Quervain's Syndrome with ultrasound (US)- guided infiltration of steroids and hyaluronic acid

Transcription

1 Treatment of De Quervain's Syndrome with ultrasound (US)- guided infiltration of steroids and hyaluronic acid Poster No.: C-2052 Congress: ECR 2014 Type: Scientific Exhibit Authors: L. Turturici 1, E. Tarabelli 2, R. Giuliani 2, I. G. Burrelli 2, P. Vagli 1, P. Keywords: DOI: Bemi 1, C. Vignali 2 ; 1 Pisa/IT, 2 Lido di Camaiore/IT Outcomes, Inflammation, Puncture, Ultrasound, Percutaneous, Musculoskeletal system, Interventional non-vascular /ecr2014/C-2052 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Aims and objectives To evaluate the effectiveness of US-guided infiltration of hyaluronic acid (HA) and steroids in the common tendon sheath of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) in the De Quervain's Syndrome in order to obtain a regression of the clinical status with functionality improvement and possibly avoiding a surgical intervention. De Quervain's Syndrome is a stenosing tenosynovitis of the first dorsal compartment of the wrist, affecting the EPB and APL tendons sheath (fig.1). This condition is caused by overuse and usually affects patients who perform repetitive movements of the thumb. Low grade chronic microtrauma at the level of the radial styloid can lead to localized thickening of the extensor retinaculum of the wrist, narrowing of the first compartment of the extensor tendons and subsequent impingement and inflammation of the EPB and APL tendons. The resulting sheath effusion and fibrotic reaction determine the formation of adhesions between the tendons and the sheath. Diagnosis is based on history and clinical examination (wrist pain, tenderness, swelling and positive Finkelstein's test), but US can be helpful to confirm it identifying thickening of the synovia and tendons, and intrasheath fluid. Finkelstein's test is performed by applying passive ulnar deviation of the wrist with the thumb maximally flexed. If sharp pain occurs along the distal radius, de Quervain's Syndrome is likely. There are both operative and non-operative treatment options. Non surgical management for De Quervain's tenosynovitis routinely involves rest, splinting, NSAIDs and intrasheath steroid injections. Steroid injections are safe, cost-effective and the most effective treatment option with as much as 83% achieving pain relief. Failure of intrasheath injections can be caused by an inaccurate injection technique or anatomic variation in the first dorsal compartment (the most frequent is a septum determining two subcompartments) therefore the use of US-guided injections represents another non-surgical option for De Quervain's management to improve the treatment outcome. Surgical therapy has been reported to be effective with a high cure rate but, compared with non surgical treatment, it is more invasive and associated with higher costs and the risk of surgical complications. Images for this section: Page 2 of 10

3 Fig. 1: The images show the location of pain and the course of the two tendons near the radial styloid process. Page 3 of 10

4 Methods and materials 34 patients with De Quervain's Syndrome were evaluated with US (fig.2) and treated with US-guided infiltration of HA and steroids. The procedure was performed percutaneously, using a sterile technique (fig.3), under US-guidance and with local anesthesia, puncturing selectively the common tendons sheath of the EPB and the APL with a 21G needle for the injection of steroids and low molecular weight (750 kda) HA. US continous monitoring (with a 7-12 MHz linear transducer) depicted the correct positioning of the needle tip inside the tendons sheath and showed the progressive intrasheath fluid distension associated to the operators feelings of detachment (fig.4). No adverse effects or complications were observed. Clinical improvement was evaluated by comparing the preprocedural and postprocedural (at 3, 6, and 12 months) clinical symptoms and disability according to QuickDASH (Disabilities of the Arm, the Shoulder and the Hand) score indexes. Images for this section: Page 4 of 10

5 Fig. 2: Transverse 7-12 MHz US images obtained over the radial styloid shows EPB and APL tendons (a) and sheath effusion around them (b). Page 5 of 10

6 Fig. 3: Sterile environment, linear ultrasound probe 7-12 MHz, anesthetic, 21G needle, hyaluronic acid, steroids. Fig. 4: US monitoring during the procedure: immediately after the needle puncture local anhestesia is performed (a), the needle tip is inserted into the common tendon sheath (b), during steroids and hyaluronic acid injection a sheath distension (arrow heads) can be appreciated (c). Page 6 of 10

7 Results Three months after the procedure, a clinical improvement up to 80% reduction of QuickDASH score indexes was recorded in 28/34 patients (82.3%), while 6 patients (17.6%) had no regression of clinical symptoms and were retreated (tab.1). At 6 months follow-up 30 patients (88.2%) achieved a significant reduction of scores except for 4 patients (11.8%) that required a new treatment (tab.2). At 12 months follow-up an important clinical relief occurred in all patients, except 4 patients that were sent to orthopaedic consultation (tab.2). Images for this section: Fig. 5: Table 1 Page 7 of 10

8 Fig. 6: Table 2 Page 8 of 10

9 Conclusion Our data show that selective infiltration under US-guidance of both steroids and hyaluronic acid in the common sheath of the EPB and APL provides a significative improvement of pain and function in the majority of patients affected by De Quervain's Syndrome avoiding a possible surgery. Personal information Emilio Tarabelli MD, U.O.C. Radiologia, Versilia Hospital, AUSL 12 of Viareggio, Lido di Camaiore, Italy; emiliorx@libero.it Riccardo Giuliani MD, U.O.C. Radiologia, Versilia Hospital, AUSL 12 of Viareggio, Lido di Camaiore, Italy; giuliani@sirius.pisa.it Italo G Burrelli MD, U.O.C. Radiologia, Versilia Hospital, AUSL 12 of Viareggio, Lido di Camaiore, Italy; italoburrelli@yahoo.it Paola Vagli MD, Department of Diagnostic and Interventional Radiology, University Hospital of Pisa, University of Pisa, Pisa, Italy; paolavagli@yahoo.it Pietro Bemi MD, Department of Diagnostic and Interventional Radiology, University Hospital of Pisa, University of Pisa, Pisa, Italy; pietro.bemi@gmail.com Laura Turturici MD, Department of Diagnostic and Interventional Radiology, University Hospital of Pisa, University of Pisa, Pisa, Italy; laura.turturici@hotmail.it Claudio Vignali MD, U.O.C. Radiologia, Versilia Hospital, AUSL 12 of Viareggio, Lido di Camaiore, Italy; c.vignali@usl12.toscana.it References Di Sante L, Martino M, Manganiello I, Tognolo L, Santilli V. Ultrasoundguided corticosteroid injection for the treatment of de Quervain's tenosynovitis. Am J Phys Med Rehabil Jul;92(7): Page 9 of 10

10 Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone and bupivacaine in the management of De Quervain's disease. Skeletal Radiol Nov;38(11): Kume K, Amano K, Yamada S, Amano K, 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 Jul;37(6): Ilyas AM. Nonsurgical treatment for de Quervain's tenosynovitis. J Hand Surg.2009;34(5):928-9 Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain's disease: role of conservative management. J Hand Surg Br. 2001;26: McDermott JD, Ilyas AM, Nazarian LN, Leinberry CF. Ultrasound-guided injections for de Quervain's tenosynovitis. Clin Orthop Relat Res Jul;470(7): Mehdinasab SA, Alemohammad SA. Methylprednisolone acetate injection plus casting versus casting alone for the treatment of de Quervain's tenosynovitis. Arch Iran Med Jul;13(4):270-4 Papa JA. Conservative management of De Quervain's stenosing tenosynovitis: a case report. J Can Chiropr Assoc Jun;56(2): Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-DeJong B. Randomised controlled trial of local corticosteroid injections for de Quervain's tenosynovitis in general practice. BMC Musculoskelet Disord. 2009;10:131 Richie CA, 3rd, Briner WW., Jr Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract.2003;16: Page 10 of 10