US-guided interventional joint procedures in patients with rheumatic diseases—When and how we do it?
Introduction
Ultrasound (US) guided interventional techniques are the most reliable way to access safely, quickly and accurately all the joints in the apendicular skeleton. In several cases rheumatic diseases need the help of ultrasonography to achieve a confident diagnosis characterizing the affected joints and evaluating disease activity. In a few cases the rheumatic disorder is only diagnosed by synovial biopsy or by joint fluid chemical and culture tests.
During chronic therapy rheumatic diseases course with acute exarcebations that must be promptly treated. During systemic therapy some joints also fail to respond and thus they benefit from intra-articular corticosteroid injections. US findings like synovial thickening, the presence of Power-Döppler signal (Fig. 1) or US-contrast enhancement indicate active synovitis (Fig. 2) and are well correlated with patient symptoms. US evaluation of the symptomatic joints improves therapeutic effectiveness of US-guided therapy by choosing the right place for injection. In those cases when a tendinitis or a tenosynovitis is present, a corticosteroid instillation in the tendon sheath can also reduce synovial inflammation and improving symptoms (Fig. 3) [1]. Yttrium-90 radiation synovectomy or radiosynoviorthesis (RSO) is another therapeutic technique based on an intra-articular image-guided infusion of a radionuclide. It intends to block intra-articular inflammation, reducing effusion, improving pain and joint swelling and thus restoring articular mobility (Fig. 4) [2], [3], [4], [5], [6].
Described techniques involve an approach with ultrasound guidance to place the needle intra-articularly. The following procedures also require a thorough knowledge of ultrasound anatomy to decide the optimum intra-articular site to perform the technique. Sonographic needle guidance significantly improves the performance and outcomes in a clinically significant manner [7].
This work describes intra-articular techniques guided by ultrasound at shoulder, elbow, wrist, metacarpophalangeal, knee, ankle and metatarsophalangeal joints.
Section snippets
Patient selection
27 patients with pain related to articular complications of rheumatic diseases and according to previous radiographic or US exam were submitted to the following US-guided procedures.
42% of patients (n = 11) had rheumatoid arthritis, 11% (n = 3) spondyloarthropathies, 18% (n = 5) psoriatic arthritis, 15% (n = 4) undifferentiated arthritis, 3% (n = 1) Sjögren syndrome and 11% (n = 3) had gout.
Procedures, articular puncture and joint specific features
- 1.
Synovial biopsy was made in 3 patients.
- 2.
Arthrocentesis/cysts drainage was made in 8 patients.
- 3.
Corticosteroid injections
Procedure details
With patient positioned on the ultrasound examination table and using an aseptic technique the surface puncture was cleaned (with alcohol or iodine solution). To the intra-articular placement of the needle all ultrasound anatomical landmarks were used, avoiding vessels, tendons or ligaments. Once the joint was entered and little resistance to injection was felt intra-articular placement was achieved. Because of the radiopharmaceutical drug (Yttrium-90) synovectomy required specific features for
Discussion/conclusion
US-guidance is very reliable to afford a safety procedure always checking the injection, biopsy or aspiration. Guided-biopsy has high success rates obtaining several samples. Thus is also possible to safely use more powerful/long acting therapeutic drugs aggressive to extra-articular structures like Triamcinolone or Yttrium-90. In clinical terms, therapeutic procedures under US-guidance, are short-term useful and very safe options in persistent synovitis unresponsive to conventional therapy.
Conflicts of interest/disclaimer
The authors declare that the submitted article is not under consideration for publication elsewhere and that they have participated sufficiently in this study to take public responsibility for its content.
All the authors or their institutions have no conflicts of interest, financial or personal relationships that inappropriately influence their actions regarding this article.
Acknowledgements
We thank to Gracinda Costa, MD and Pedro Abreu, MD by their support in the Radiosynoviorthesis. We thank also to Lara Rodrigues, MD for the help in the provided illustrations.
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