The infiltration of the AC joint performed by one specialist: Ultrasound versus palpation a prospective randomized pilot study

doi:10.1016/j.ejrad.2009.06.018

European Journal of Radiology

Volume 75, Issue 1, July 2010, Pages e37-e40

https://doi.org/10.1016/j.ejrad.2009.06.018 Get rights and content

Abstract

Introduction

The acromio-clavicular (AC) joint is very susceptible to degenerative processes that result in pain and functional impairment. One common modality of treatment has been local infiltration of the joint space. Although this procedure has produced notable positive results, needle misplacement occurs frequently. The aim of this investigation is to evaluate the effects of an intra articular infiltration by comparing precise needle placement into the joint space using high-resolution-ultrasound with the conventional palpation technique.

Methods

This prospective and randomized pilot study analysed 20 patients who were assigned either to the “ultrasound” or the “palpation” group. Clinical examinations were performed before treatment and at 1 h, 1 week and 3 weeks after a single infiltration of local anaesthetic and corticoid carried out by one specialist.

Results

In both groups significant improvement in pain and function was obtained up to one-week post injection. Function remained significantly improved until the last follow-up and did not differ between the two groups. The agent was administered in all patients into the joint space in the ultrasound group.

Conclusion

Ultrasound guided infiltration of the AC joint is an easily achieved procedure without any complications. However, clinical follow-up did not differ between free-hand and ultrasound-guided AC joint space infiltration.

Introduction

The clavicle is the only bony connection between the upper extremity and the thorax. It forms a diarthrodial joint at the distal end with the acromion. This articulation is termed acromio-clavicular (AC) joint and is surrounded by ligaments and the capsule. As the surfaces of the distal Clavicle and the medial part of the Acromion are incongruent, a fibro-cartilagenous disc called the meniscoid increases the contact area between the two bones. The joint space varies in size and especially angulation. Due to rotational and shear forces occurring in the AC joint, the meniscoid progressively degenerates. Traumatic injury, specifically dislocations at the AC joint accelerate these degenerative changes. The osteoarthrosis of the AC joint is found in many patients in their third decade and is regularly observed in older patients. Most frequently, patients report having a painful arc that is symptomatic in high anteversion and elevation. Palpation of the shoulder girdle often reveals a tender spot in the overlying the AC joint. Local pain can be increased with the arm adduction test. During this test, the affected arm is put into 90° of anteversion and then passively adducted. As the clavicle is pressed onto the acromion, pain may develop.

Conventional radiography is mandatory to establish the proper diagnosis. Joint narrowing and prominent osteophytes at the AC joint are commonly seen in cases of osteoarthritis. MRI especially in combination with a superficial coil [1] can visualize the structures of the AC joint including the meniscoid and other bony and soft tissue pathologies of the shoulder joint. Additionally, CT scans can be helpful to evaluate specifically the bony situation. High-resolution ultrasound (US) is a well-established tool in the diagnostic algorithm of shoulder disorders. It is particularly helpful when investigating tendon injuries in the subacromial space. The advantage of using US at the AC joint is to precisely localize the joint space and identify any possible effusions or swelling of the surrounding soft tissue. Experience and appropriate US equipment, including a linear transducer with a minimum range of 10 MHz, are mandatory for effective shoulder imaging.

Another common tool to identify AC joint pathology is local infiltration with either a local anaesthetic or a combination of such with a corticoid. Studies have revealed that there is a positive short-term effect [2], [3], [4]. The average pain free interval lasted approximately three weeks. Unfortunately, the infiltration of small joints, like the AC joint, is difficult even in experienced hands. The average rate of misplaced active agent is reportedly 50–60% [2], [5].

This pilot study was planned to evaluate whether US guidance for infiltration in the symptomatic AC joint is feasible and improves the clinical outcome when compared with traditional palpation and injection.

Section snippets

Materials and methods

Twenty patients were enrolled in this prospective, randomized pilot study trial, which was approved by the ethics committee of the author's hospital (494/08). Patients were recruited at the department's outpatient shoulder clinic after having passed the inclusion criterion (Table 1). The population was then divided into two equal groups with randomization performed by the department of medical statistics. For each enrolled study subject, a preformed envelope was provided, containing the

Results

All included 20 patients (11 male/9 female) completed the entire study protocol. The mean age of this population was 51.3 (±13.28) years with a mean height of 169 cm (±10.76) and a mean weight of 76.59 (±18.38) kg. 15 right and 5 left shoulders were treated. Nine patients had a shoulder trauma in their history, of which three had an AC-dislocation. No patient had a history of previous surgery on the affected shoulder. In all patients of the ultrasound group the needle was accurately positioned

Discussion

The ability to introduce a needle accurately into the joint space plays a crucial role in diagnosis, and treatment of AC joint pathology. In small joints like the AC joint with an intra artricular meniscoid, even in experienced hands, appropriate injection of the active agent is obtained in only 40–50% and in only 70% in the subacromial space [8]. In massive osteoarthritis of the AC joint, the resection of the distal clavicle is a common treatment option [9], [10]. The results of diagnostic

Conclusion

The infiltration of the AC joint using a combination of a local anaesthetic and a corticoid is a helpful, cheap and quickly administered treatment option in symptomatic AC joints. The duration of pain relief with improved shoulder function was highly significant in the first week after therapy. Three weeks after therapy, the pain at the AC joint returned to baseline levels but the improvement in function was still significant. The exact localisation of the AC joint using high-resolution US was

Conflict of interest

There is no conflict of interest. This investigation was not supported financially or in any other way.

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The acromioclavicular (AC) joint is a diarthrodial joint found between the lateral end of the clavicle and the medial side of the acromion. The AC ligaments cross the joint. The coracoclavicular ligament begins at the coracoid process on the scapula and attaches to the clavicle. This complex provides passive support and suspension of the scapula from the clavicle while allowing rotation of the clavicle to be transmitted to the scapula. Injuries to the AC complex have traditionally been graded I to VI and are associated with trauma, overhead activities, or throwing activities. Types I and II and stable type III can be managed nonsurgically. Patients present with pain and a deformity at the AC joint. Examination can differentiate between isolated AC injuries or concomitant fractures or rotator cuff injuries. Conservative treatment includes modalities, relative rest, and possible immobilization for several weeks. Restoring motion and returning to activity occur as symptoms resolve and athletes can return to prior functional levels. Surgical treatment for unstable injuries requires longer periods of immobilization and rehabilitation. Most patients can return to chosen occupations or sports after surgical treatment. Complications are typically cosmetic. Type III injuries that fail conservative treatment can respond to surgery with good results at a later date.
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Citation Excerpt :
While the preliminary research suggests that USGIs are more cost-effective than LMGIs, further research is required before making a final determination on the cost-effectiveness of USGIs. Twenty-three studies assessing injections into intermediate sized joints were identified (see online supplementary Appendix 2) [8,16,26,31,52,63-80]. Seventy-four percent (17/23) of the studies evaluated injections into a single joint [8,63-65,67-70,72-80] and 26% (6/23) assessed injections into multiple joints [16,26,31,52,66,71].
The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based upon the evidence, the official AMSSM position relevant to each subject is made.
Successful injection of the acromioclavicular joint with use of ultrasound: Anatomy, technique, and follow-up
2014, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
The techniques in cadaver studies either employ an inordinately thick needle required for reliable out-of-plane needle visualization3 or use the type of in-plane techniques17 for scalene blocks and biopsies, which are technically difficult and painful to reproduce in vivo. Some clinical work has been done, notably the pioneering studies of Sabeti-Aschraf et al,21,22 but these authors do not provide irrefutable verification of the needle in the joint, and furthermore their technique raises concerns about sterility. These concerns were implicitly acknowledged by the authors, who themselves suggest the type of sterile precautions we have taken in our study.20
Injection into the acromioclavicular (AC) joint is often inaccurate (approximately 50%) even in experienced hands. In light of new anatomic observations, we evaluate accuracy of an innovative ultrasound-guided method and follow the clinical course of successful therapeutic injections.
Relevant anatomy was investigated in 200 three-dimensional computed tomography scans, 100 magnetic resonance images, and 14 cadavers. Baseline measurements of joint depth and width were performed ultrasonically in 100 normal volunteers; 50 symptomatic patients were injected. Uniquely in a clinical ultrasound study, injection success was documented by arthrography. Outcomes after concomitant steroid instillation were observed for 6 months by visual analog scale (VAS) scores and pain provocation test results.
Anatomic studies showed that the widest area for joint penetration was anterior superior. Injection success rate was 96%, overwhelmingly on the first needle pass. Shallow joint depth allowed access with a standard 3-cm needle. Joint width diminished with age but did not reduce injection success. Cadaveric joints admitted 1.2 ± 0.5 mL, but fluid ingress was initially blocked by soft tissues in one third of both cadaveric and clinical cases. Diligent follow-up after steroid injection showed sustained pain relief in the majority with isolated AC disease but significantly less in those with concomitant shoulder disorders.
This high level of clinical injection success, irrefutably substantiated with arthrography, has not been previously demonstrated. The anterior superior aspect of the joint is the preferred place for entry. Initial intra-articular blockage to fluid inflow is common but can be surmounted. Encouraging 6-month results of steroid instillation in isolated AC disease do not apply to patients with coexisting shoulder pathologic processes.

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The infiltration of the AC joint performed by one specialist: Ultrasound versus palpation a prospective randomized pilot study

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Conflict of interest

Clin Sports Med

Arthroscopy

Ultrasound Med Biol

Visualization of intraarticular structures of the acromioclavicular joint in an ex vivo model using a dedicated MRI protocol

Am J Roentgenol

The long-term efficacy of corticosteroid injection into the acromioclavicular joint using a dynamic fluoroscopic method

Int J Shoulder Surg

Therapeutic efficacy of corticosteroid injections in the acromioclavicular joint

Biomed Sci Instrum