Ultrasound-assisted musculoskeletal procedures:A practical overview of current literature

Traditionally performed by a small group of highly trained specialists,bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment.Due to this limitation,a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel.The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios.This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures.In-depth discussion of each ultrasound procedure including pertinent technical details,indications and contraindications is provided.Despite the limited amount of prospective,randomized data in this area,a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

The Effect of Tramadol Hydrochloride In-traarticular Injection on IL-6 Level in Patients with Tempromandibular Joint Internal Derangement

Purpose: This study was conducted to detect IL-6 in synovial fluid in cases with TMJ internal derangement. Patients & Methods: This study was conducted on forty patients ASA class I with TMJ Internal derangement. All patients had been subjected to arthrocentesis. The synovial fluid was collected before wash and lavage was done for the affected joint. Then, the selected patients were divided randomly into two equal groups, group I: consisted of 20 patients where arthrocentesis was performed for the affected joint followed by intraarticular injection of one ml, tramadol hydrochloride. Group II: consisted of 20 patients where arthrocentesis was performed for the affected joint followed by intraarticular injection of one ml. sodium hyaluronate. Another synovial fluid sample was aspirated after one month. The interlieukin-6 receptors in the aspirated synovial fluid were measured using humans IL-6 enzyme-linked immunosorbent assay. Results: IL-6 was detected in the synovial fluid of joints with internal derangement. During follow up assessment of IL-6, the maximum decrease in IL-6 level was in the patients of group I who subjected to arthrocentesis with tramadol injection, as the mean IL-6 was (4.93 ± 1.36) followed by the patients of group II who subjected to arthrocentesis with sodium hyaluronate injection where the mean IL-6 level was (6.88 ± 1.76). There were significant p-value = (P = 0.000). Conclusions: It had been concluded that the detection of IL-6 in the synovial fluid of joints with internal derangement considered an indicator for inflammatory reaction in the joint and also the efficacy of arthrocentesis with tramadol suggested its anti-inflammatory effect.

Management of periprosthetic infections

Periprosthetic joint infection(PJI) is considered one of the most challenging complications compromising patient health and is considered an economic burden.Despite all strategies PJI prevalence is between 1%-2%. Considerable efforts have been investigated in the past decade to diminish or erradicate PJI prevalence. This article manages the definition of PJI and the new major and minor criteria from Parvizi et al Then a scientific analysis of every minor and major criteria. Multidisciplinary management is reccommended according to guidelines. A numerous of surgical options exist each and everyone with its indications,contraindications and specific antibiotic therapy regimen. Surgical options are:(1) irrigation and cleaning with retention of the prosthesis with a success rate 0%-89%;(2) single-stage revision surgery with a succes rate of > 80%; and(3) two-stage revision surgery(authors preferred method) with a succes rate of 87%. Radical treatment options like arthrodesis and amputation are reserved for specific group of patients,with a succes rate varying from 60%-100%. The future of PJI is focused on improving the diagnostic tools and to combat biofilm. The cornerstone of management consists in a rapid diagnosis and specific therapy. This article presents the most current diagnostic and treatment criteria as well as the different surgical treatment options depending on the type of infection,bacterial virulence and patient comorbidities.

Synovial White Cell Count in the Diagnosis of Septic Arthritis: Are Current Diagnostic Practices Appropriate?

Introduction & aims: Septic arthritis is an emergency, potentially causing irreversible joint destruction and disability. Synovial WCC and polymorphonuclear cell percentage are the best predictors of septic arthritis likelihood. Yet, synovial white cell and differential count are not routinely assessed. We aim to investigate the incidence of failure to perform these tests, and to develop correct synovial fluid analysis practices. Method: This is a retrospective analysis of native joints having undergone arthrocentesis for suspicion of septic arthritis at Box Hill Hospital (BHH) during September 2011 and September 2013 inclusive. Recruitment was from the Eastern Health Decision Support Service (DSS), a database compiled from all systems within Eastern Health, of which BHH is a member. The study was limited to large joints, including hip, knee and shoulder. All prosthetic joints were excluded from the patient population. All patient histories were examined for suspicion of septic arthritis and subsequent arthrocentesis. Pathology records were accessed to determine incidence of cell count and differential. Results: One hundred and thirty-six cases of joint aspirations were identified within the time frame, of which sixty-seven fitted our criteria for evaluation. All but two cases were delivered using the DSS, which was limited to data compiled only until June 2013. The two remaining cases were identified with a manual search of the radiology and pathology databases from June to September 2013. 22 of the 67 joint aspirates studied did not have a cell count carried out. Four of these 22 cases had a diagnosis of septic arthritis. In five aspirates, there was a failure to confirm a definite diagnosis and they were thus conservatively treated as a septic joint. The remaining acute joints in which no cell count was done were gout (7 cases), pseudogout (5 cases) and rheumatoid arthritis (1 case). Cell counts were not routinely detected for a variety of reasons. Eleven aspirates were deemed too viscous, and in eight cases the sample had clotted prior to pathologist assessment. Two cases had insufficient volume, and one sample was too bloodstained to calculate a cell count and differential;likely due to traumatic aspiration. Conclusions: 33% of acute monoarthritis’ evaluated over the study period failed to have a synovial fluid WCC and differential. This may be due to inadequate samples, or lack of appropriate collection tube. Better education is required for appropriate collection and test requesting wherein a diagnosis of septic arthritis is in question.

Treatment of chronic recurrent dislocation of temporomandibular joint by autologus blood injection

Aim:The aim of this study was to evaluate the efficacy of autologus blood injection in the management of recurrent temporomandibular joint(TMJ)dislocation.Methods:A total of 11 patients,4 males,7 females,mean age of 58.6 years and suffering from recurrent dislocation of TMJ,were included in the study.In all the patients the procedure included anesthesia-local or sedation,arthrocentesis which was followed by autologous blood injection in the upper joint cavity.The peri-articular tissues were also infiltrated with autologous blood.Post procedure advice included restricted mouth activity and liquid diet for a month.Results:The results indicate that success rate of treatment of recurrent dislocation of TMJ is 72.8%which can be considered as impressive.The recurrence was noticed in 27.2%cases after one year follow up.Conclusion:Autologus blood injection is an effective,simple,non-invasive,and safe procedure for treatment of recurrent dislocation of TMJ and can be performed on outpatient basis.

Internal derangement of temporomandibular joint: role of arthocentesis with steriod

Aim:The aim of this study was to compare the efficacy of arthrocentesis with arthrocentesis plus steroid in the treatment of temporomandibular joint(TMJ)internal derangements.Methods:Nine males and 11 females aged 17–39 years were enrolled in the study.The patients were complaining of limited mouth opening and TMJ pain.Arthrocentesis was performed under aseptic conditions.All patients were clinically evaluated before the procedure,and 1 week and 6 months after the procedure.Intensity of TMJ pain and maximal mouth opening was recorded at each follow-up visit.Results:Both groups showed significant improvement in mouth opening and a reduction in pain scores in the postoperative period;however,the addition of steroid did not improve the overall outcome of the procedure.Conclusion:Arthrocentesis is a simple and safe procedure for patients with internal derangement of the TMJ with closed lock.However,the outcome was not improved by the addition of steroid.