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Less Painful, More Effective Joint Injections Using Ultrasound

ATLANTA - The use of ultrasound needle guidance improves the performance, outcomes and the cost-effectiveness of knee injections in people with osteoarthritis.

Osteoarthritis, or OA as it is commonly called, is the most common joint disease affecting middle-age and older people. It is characterized by progressive damage to the joint cartilage—the slippery material at the end of long bones—and causes changes in the structures around the joint. These changes can include fluid accumulation, bony overgrowth, and loosening and weakness of muscles and tendons, all of which may limit movement and cause pain and swelling.

Researchers recently set out to determine if the use of ultrasound guidance would affect the outcomes of intraarticular injections—injections of medicine into, or removal of fluid from, arthritic joints—in people with knee OA. "Ultrasound, the use of sound waves to visualize the human body, is useful to physicians to guide the needle into the joint to inject medications to treat arthritis," explains Wilmer Sibbitt, Jr., MD; professor of rheumatology and neurology, University of New Mexico Health Sciences Center, Albuquerque, N.M. and an investigator in the study.

Dr. Sibbitt's research team studied 94 knees, which were randomly selected for injection administered either by the conventional palpation-guided method or by the newer ultrasound-guided method (which allowed researchers to watch, in real time, the needle entering and exiting the joint).

Both the palpation and ultrasound-guided methods involved one needle, with a syringe attached, entering the joint to remove fluid from it. After that was accomplished, the first syringe was removed (with the needle remaining inserted) and a second syringe was used to inject 80mg of a corticosteroid through the same needle. This technique ensured the medication was injected into the correct place. When using the ultrasound-guided method, researchers were able to perform the procedure while confirming needle placement as well as administration of the lidocaine and the corticosteroid by viewing the procedure as it occurred.

Each participant's initial pain, pain during the procedure, and knee pain at the end of two weeks and six months were studied. Researchers looked at who responded to the treatment, the length of time the participants experienced pain relief after the injection, how often participants needed to be reinjected, the total cost of the procedure, and the cost per participant who responded to the treatment.

When compared to the palpation-guided method, researchers found the use of the ultrasound-guided method to provide improved results - including a 107 percent increase in the number of people who responded to the treatment and a 51.6 percent reduction in the number of people who did not.

Additionally, researchers noted a 47 percent reduction in pain during the procedure, a 41.7 percent reduction in pain two weeks after the injection, and a 35.5 percent increase in the length of time the participants experienced pain relief after the injection.

Finally, researchers compared the cost effectiveness of the ultrasound-guided method to the traditional palpation method. They found that the ultrasound method led to a 14.6 percent ($48) reduction in cost per participant per year and a 58.8 percent ($593) reduction in the cost per hospital-outpatient participant who responded to the treatment.

These results have led researchers to believe that the use of ultrasound-guidance in intraarticular injections is an approach that can improve the overall treatment of knee OA, which will improve treatment costs as a patient's need for additional expensive treatments can be reduced.

"The study demonstrates that when physicians use ultrasound and a technique called hydrodissection performed with precise new mechanical syringes to inject the joint, the patient experiences less pain, improved safety, a better response to medications, and less need for other medical therapy," says Dr. Sibbitt. "Rheumatologists are increasingly using ultrasound, and patients should be aware that joint injections may be more effective and less painful if their physician offers this option to them."

Patients should talk to their rheumatologists to determine their best course of treatment.

The American College of Rheumatology is an international professional medical society that represents more than 8,000 rheumatologists and rheumatology health professionals around the world. Its mission is to advance rheumatology. The ACR/ARHP Annual Scientific Meeting is the premier meeting in rheumatology. For more information about the meeting, visit . Follow the meeting on twitter by using the official hashtag: #ACR2010.


Editor's Notes: Natalia R. Chavez-Chiang, MD will present this research during the ACR Annual Scientific Meeting at the Georgia World Congress Center at 10:15 AM on Thursday, November 11 in Room A 410. Dr. Sibbitt will be available for media questions and briefing at 1:30 PM on Monday, November 8 in the on-site press conference room, B 212.

Learn more about living well with rheumatic disease as well as rheumatologists and the role they play in health care.

Presentation Number:2225


Natalia R Chavez-Chiang,MD
(University of New Mexico Health Sciences Center, Albuquerque, N.M.)

Wilmer L Sibbitt,MD
(University of New Mexico Health Sciences Center, Albuquerque, N.M.)

Suzanne Delea,MD
(University of New Mexico Health Sciences Center, Albuquerque, N.M.)

Kye Park,MD,MPH
(University of New Mexico Health Sciences Center, Albuquerque, N.M.)

Arthur D Bankhurst, MD
(University of New Mexico Health Sciences Center, Albuquerque, N.M.)

Philip A Band
(New York University Medical Center, New York, N.Y.)

Hillary Norton
(University of New Mexico Health Sciences Center, Albuquerque, N.M.)

Body: Objective: The present randomized controlled study addressed whether sonographic needle guidance affected the outcomes of intraarticular injection for osteoarthritis of the knee.

Methods: 94 non-effusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed RPD (the reciprocating procedure device) syringe. A one needle, two-syringe technique was used. After intraarticular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intraarticular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

Results: Relative to conventional palpation-guided methods, sonographic guidance for injection of the knee resulted in 47.7% reduction in procedural pain (p<0.001), a="" 41.7%="" reduction="" in="" pain="" scores="" at="" outcome=""><0.03), 107%="" increase="" in="" the="" responder="" rate=""><0.001), 51.6%="" reduction="" in="" the="" non-responder="" rate=""><0.001), a="" 35.5%="" increase="" in="" therapeutic="" duration="" (p="0.01)," a="" 14.6%="" reduction="" ($48)="" in="" cost/patient/year,="" and="" a="" 58.8%="" ($593)="" reduction="" in="" cost/responder/year="" for="" a="" hospital="" outpatient=""><>

Conclusions: Sonographic needle guidance improves the performance, clinical outcomes, and cost-effectiveness of intraarticular injections of the osteoarthritic knee.

1915 Figure 2 Sibbitt B&W

1915 Figure 3 US Injection of knee

1915 figure 4 US color doppler

Disclosure: Natalia Chavez-Chiang, nothing to disclose; Wilmer Sibbitt, Becton Dickinson : Consulting fees Celgene: Stock, stock options or bond holdings, Ferring Pharmaceuticals Inc. : Consulting fees, Apple, Inc: stock, stock options or bond holdings, Avanca Inc: Stock, stock options or bond holdings, Avanca Medical Devices: Consulting fees, Avasca inc: Stock, stock options or bond holdings, Avasca Medical Inc: Consulting fees, Inteligence Management Solutions: Consulting fees, Java Inc: Stock, stock options or bond holdings, Meditech Duopross: Consulting fees, Sun Mycrosystems: Stock, stock options or bond holdings, Symmantec Corp: Stock, stock options or bond holdings, US National Institutes of Health: Research grants; Suzanne Delea, nothing to disclose; Kye Park, nothing to disclose; Arthur Bankhurst: nothing to disclose; Philip Band: nothing to disclose; Hillary Norton: nothing to disclose.

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