us guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86...
TRANSCRIPT
![Page 1: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/1.jpg)
US guided techniques in the lower extremity
Elena Drakonaki MD, PhD, PostDocConsultant MSK Radiologist
Heraklion, Greece & Oxford, UK
![Page 2: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/2.jpg)
TOPICS
• Intra articular injections hip, knee, ankle & foot
www.drakonaki.gr
• Soft tissue injections and techniques:Gluteal tendinopathy –Greater trochanteric BursaPatella tendinopathyPlantar fasciitisAchilles tendinopathyAnkle tendon sheath injectionsMortons neuromasNerve BlocksBursae and Ganglia
![Page 3: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/3.jpg)
OFFICE-BASED SET UP• High resolution US systems• High frequency (6-18MHz) linear probes• Ergonomic probes• Ergonomic set up for patient positioning• Trained nurse/helper• First Aid Equipment
www.drakonaki.gr
Intraarticular Injections
![Page 4: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/4.jpg)
PROTOCOL
• Confirm the indication (history, imaging)• Consent & Complications• Sterile Conditions• Aftercare instructions (rehabilitation)• Follow up (pain diaries-VAS scores)
• Checklist
www.drakonaki.gr
Intraarticular Injections
![Page 5: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/5.jpg)
Intra-articular injection HIPwww.drakonaki.gr
• longitudinal along the femoral neck • mark the skin at the site of puncture• Identify the femoral artery (medial to puncture)• 5 ml of 1 % Lignocaine subcutaneously • 22 G spinal needle • needle obliquely onto the femoral neck
Short axis
Longitudinal
![Page 6: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/6.jpg)
Intra-articular injection KNEEwww.drakonaki.gr
Using contrast injection to verify accuracy:
•1/3 of blind knee injections were inaccurate•US-guided injections by trainee more accuratethan the blind by senior rheumatologist
(83% versus 66%)
A randomized, double-blind, controlled study of guided corticosteroid injection in patients with inflammatory arthritis. Cunnington J, Arthritis Rheum 2010
Very easy to perform blindly-so WHY US?
Cunnington J, Arthritis Rheum 2010Sibbitt et al, J Clin Rheumatol 2011Sibbitt et al, Scand J Rheumatol, 2012Bercoff et al, Clin Interv Aging 2012
Better accuracy than anatomical guidance (95.8% vs 77.8%)
![Page 7: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/7.jpg)
Intra-articular injection KNEEwww.drakonaki.gr
Axial view over Suprapatella pouch
![Page 8: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/8.jpg)
Intra-articular injection ANKLE joint www.drakonaki.gr
Avoid artery and tendons,the needle inserted from distal probe edge parallel to its long axis towards the joint space
![Page 9: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/9.jpg)
Intra-articular injection FOOT www.drakonaki.gr
• 23G blue needle• No local anaesthetic• May use bend needles • parallel to transducer •1ml steroid and 1 ml anaesthetic
![Page 10: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/10.jpg)
www.drakonaki.grUS guided Peritendinous injections
• 23G blue needle•May use bend needles •No local anaesthetic• parallel to transducer •1ml steroid and 1-2 ml anaesthetic•AROUND tendon (into the sheath)
![Page 11: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/11.jpg)
www.drakonaki.gr
Achilles Tendinosis: TherapyDry needling
PRP-autologous blood injections
Sclerosing/dextrose injections
Paratendon stripping/Brisement
High volume Injections
20-40 mls salineAnaestheticNo steroid
OUTCOME (4w)Reduce neovascularizationReduce tendon thickness
Improve symptoms
US guided Tendon injections
![Page 12: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/12.jpg)
EUROSON 2013, Stuttgartwww.drakonaki.gr
Patella Tendinosis: Therapy
Dry Needling(to stimulate healing response by platelet cascade)
+/- steroid, PRP, Tenocyte, sclerosing injections
Sclerosing injections: effective at 2/3 at 44wTesta V et al, Med Sci sports Exces 1999Hoksrud et al, Am J Sport Med 2011
Dry needling: effective for mid tendon but not for insertional tendinopathy
Testa V et al, Med Sci sports Exces 1999Hoksrud et al, Am J Sport Med 2011Testa V et al, Med Sci sports Exces 1999Hoksrud et al, Am J Sport Med 2011Testa V et al, Med Sci sports Exces 1999Hoksrud et al, Am J Sport Med 2011Testa V et al, Med Sci sports Exces 1999Hoksrud et al, Am J Sport Med 2011
Dry Needling(to stimulate healing response by platelet cascade)
+/- steroid, PRP, Tenocyte, sclerosing injections
Testa V et al, Med Sci sports Exces 1999Hoksrud et al, Am J Sport Med 2011
US guided Tendon injections
![Page 13: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/13.jpg)
www.drakonaki.gr
Plantar Fasciitis
Reduce pain and swelling 4 weeksDry needling + steroid
McNally et al, Semin MSK Radiol 2010
US guided Tendon injections
Be aware of lateral plantar nerve Injury
Insert needle from the lateral side
![Page 14: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/14.jpg)
www.drakonaki.gr
Plantar Fasciitis
Reduce pain and swelling 4 weeksDry needling + steroid
McNally et al, Semin MSK Radiol 2010
US guided Tendon injections
Subcutaneous Lidocaine injection Dry needling
![Page 15: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/15.jpg)
NERVESMorton’s Neuromas
• Transducer along the axis of the metatarsal bones• Shift across each MTP joint and identify the neuroma• 23G blue needle with 1ml steroid and 1 ml anaesthetic • Needle is inserted through the interdigital fold parallel to long axis of transducer• the needle is visualized at the bottom left side of the US screen
![Page 16: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/16.jpg)
NERVESPeripheral Nerve Blocks
Tagliafico et al, JUM 2011
Lateral Femoral Cutaneous nerve block
Peroneal nerve block
![Page 17: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/17.jpg)
SOFT TISSUEGanglia, Bursae Injections
Tibiofibular joint ganglion aspiration Semimembranosus bursitis
Greater trochanteric bursa injection
www.drakonaki.gr
![Page 18: US guided techniques in the lower extermity¿μιλια της κ Δρακωνακη... · 86 jxlghg whfkqltxhv lq wkh orzhu h[wuhplw\ (ohqd 'udnrqdnl 0' 3k' 3rvw'rf &rqvxowdqw 06](https://reader033.vdocuments.site/reader033/viewer/2022060211/5f04dbb97e708231d4100fea/html5/thumbnails/18.jpg)
www.drakonaki.grUS-guided MSK intervention
Thank you