US-guided steroid and hyaluronic acid infiltration for the treatment of hand and wrist tenosynovitis: Preliminary experience Poster No.: C-2342 Congress: ECR 2010 Type: Scientific Exhibit Topic: Musculoskeletal Authors: L. Callegari, A. Bini, E. Spanò, M. Barresi, A. Leonardi, E. Genovese, C. Fugazzola; Varese/IT Keywords: Hyaluronic Acid, US interventional, tenosinovitis DOI: 10.1594/ecr2010/C-2342 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. www.myesr.org Page 1 of 12
Purpose Tenosynovitis is an inflammatory process of tissue coating tendon resulting "overuse". of the fluid-filled sheath (called the synovium) that surrounds a tendon [Fig.1 on page 2, Fig.2 on page 3]. Causes of tenosynovitis are unknown, repeated use of hand tools can precede the condition, as well as arthritis or injury. Tenosynovitis sometimes runs in families and is generally seen more often in males than in females. Symptoms of tenosynovitis include pain, swelling and difficulty moving the particular joint where the inflammation occurs. It usually occurs with tendinitis and it is related to stenosing tenosynovitis. Treatments for tenosynovitis depend on the severity of the inflammation and location. Mild tenosynovitis causing small scale swelling can be treated with non-steroidal antiinflammatory drugs (NSAID) taken to reduce inflammation and as an analgesic. Physical or Occupational therapy may also be beneficial in reducing symptoms [1]. More acute cases are treated with steroid injection. Outpatient surgery can be used to enlarge the synovium. The sprained tendon or limb is splinted for a week or so. The purpose of this study is to demonstrate the effectiveness of the US-guided infiltration of steroids and Hyaluronic Acid (HA) as a valid alternative to conservative and surgical treatments. Images for this section: Page 2 of 12
Fig. 1 Page 3 of 12
Fig. 2: Ultrasound of tenosynovitis of flexor finger. The movie show: presence of fluid in the tendon sheath, synovium thickening and increase of intra-articular power Doppler signal. Page 4 of 12
Methods and Materials From January 2006 to December 2007 we have treated 24 patients, 15 males and 9 females, average 40 years (range 25-55 years), with pain, tenderness and sometimes swelling of the affected part of the tendon. The pain was typically exacerbated with the movement and conditioned normal daily activities. All patients performed a clinical evaluation and an ultrasound exam. Ultrasound criteria for diagnosis of tenosynovitis of flexor finger and I extensor compartment of the hand, were the presence of fluid in the tendon sheath [Fig.1 on page 6, Fig.2 on page 5], synovium thickening [Fig.3 on page 6] and increase of intra-articular power Doppler signal, indicative of active inflammation [Fig.4 on page 7, Fig.5 on page 7, Fig.6 on page 8, Fig.7 on page 8 ]. All patients underwent infiltration, the procedure requires: need 25 G, syringes (2.5 cc for steroid, from 2 cc to the ac. Hyaluronic), 17-MHz probe, vaseline oil, sterile gloves and drugs: corticosteroid, local anesthetic and hyaluronic acid. Patients were injected under steril condictions with steroid and lidocaine 2% under usguidance using 17 MHz probe (Philips IU22), with 25 G needle was effected puncture of the tendon sheath, after aspiration of inflammatory fluid, infiltration was made. [Fig.8 on page 9, Fig.9 on page 9]. After 10-15 days a second injection was done with 1 cc of medium-low weight HA [Fig.10 on page 10]. All patients were evaluated clinically (VAS, articular, Force, DASH) before and after the procedure. Follow-up was done at 6 weeks and at 6 months. Images for this section: Page 5 of 12
Fig. 1: US longitudinal scan: presence of fluid in the tendon sheath. Fig. 2: US longitudinal scan: presence of fluid in the tendon sheath. Page 6 of 12
Fig. 3: US longitudianl scan show synovium thickening. Fig. 4: US axial scan show increase of intra-articular power Doppler signal, indicative of active inflammation. Page 7 of 12
Fig. 5: US axial scan show increase of intra-articular power Doppler signal, indicative of active inflammation. Fig. 6: US longitudinal scan show increase of intra-articular power Doppler signal, indicative of active inflammation. Page 8 of 12
Fig. 7: US longitudinal scan show increase of intra-articular power Doppler signal, indicative of active inflammation. Fig. 8: US puncture of the tendon sheath with 25 G needle, aspiration of fluid. Page 9 of 12
Fig. 9: US puncture of the tendon sheath with 25 G needle Fig. 10: US puncture of the tendon sheath with 25 G needle, injection of Hyaluronic Acid. Page 10 of 12
Results Technical success was 100%. Good clinical results were obtained with improvement of all clinical and functional parameters. Time abstention from work and /or sport was 4-5 days. No periprocedural local or systemic complication occurred. Conclusion Us-guidance allows to avoid erroneous injections of the drug and tendons lesions. The use of Hyaluronic Acid thanks to its characteristics, reduces the possible effects of corticosteroids and improves clinical outcomes. Low invasiveness of procedure allows fast return at work or sport. This procedure has also low costs both economic and social. References 1. Andres BM, Murrel GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54. Page 11 of 12
Personal Information Dr. Leonardo Callegari, Departement of Radiology, University of Insubria, Varese. Dr. Amedeo Bini, Departement of Ortgopedic, University of Insubria, Varese. Dr.ssa Emanuela Spanò, Departement of Radiology, University of Insubria, Varese. Dr.ssa Maria Barresi, Departement of Radiology, University of Insubria, Varese. Dr.ssa Anna Leonardi, Departement of Radiology, University of Insubria, Varese. Prof.Eugenio Genovese, Departement of Radiology, University of Insubria, Varese. Prof. Carlo Fugazzola, Departement of Radiology, University of Insubria, Varese. Page 12 of 12