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Septic Bursitis After Ultrasound-guided Percutaneous Treatment of Rotator Cuff Calcific Tendinopathy
Case Presentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55
Septic Bursitis After Ultrasound-guided Percutaneous Treatment of Rotator Cuff Calcific Tendinopathy Q7 Q1
Luca Maria Sconfienza, MD, PhD, Filippo Randelli, Silvana Sdao, Francesco Sardanelli, Pietro Randelli Calcific tendinopathy of the rotator cuff is a common condition. Ultrasound-guided percutaneous aspiration is one of several options to treat this condition. The main advantages of this procedure are short duration, good outcome, and low cost. Furthermore, only minor complications have been reported in the literature, namely, vagal reactions during the procedure and mild postprocedural pain. We report the first case of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy. Although this is generally considered a very safe procedure, a risk of infection should be taken into account. PM R 2014;-:1-3
INTRODUCTION
Q2
Calcific tendinopathy of the rotator cuff is a common condition [1]. Intratendinous calcifications can be found in up to 7.5% of asymptomatic shoulders and in up to 20% of painful shoulders [1,2]. When symptomatic, calcific tendinopathy can be very painful and disabling for patients, thus requiring prompt treatment. Several options have been proposed to treat this condition [1-4]; currently, ultrasound-guided percutaneous aspiration is one treatment option [5,6]. This procedure can be performed with a number of approaches. The main difference among these approaches is the use of 1 or 2 needles to aspirate calcium under ultrasound guidance [1-5]. The main advantages of these procedures are the short duration, the good short- and long-term outcomes, and the relatively low cost [1-7]. Furthermore, only minor complications have been reported, namely vagal reactions during the procedure and mild postprocedural pain [1-7]. We report the first case, to our knowledge, of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy of the rotator cuff.
CASE PRESENTATION
Q3
A 44-year-old male patient was referred to our radiology clinic for aspiration therapy for a 22-mm intratendinous calcium deposit in the right supraspinatus tendon. He reported moderate pain that lasted for approximately 6 months that was associated with limitation in abduction movement of his right arm. The patient was in good health, with no known condition that would contraindicate the aspiration procedure. The injection area was prepared according to standard sterile protocol [1,2]. With the patient lying supine on the bed, the skin was cleaned with a solution of iodopovidone 10% for 2 minutes and then cleaned again with benzalkonium chloride 0.25% solution to ensure complete sterilization and to avoid probe staining. Sterile drapes were subsequently applied. The ultrasound probe (6- to 13-MHz high-resolution broadband linear array transducer and MyLab 70 XvG ultrasound system; Esaote, Genova, Italy) was thoroughly cleaned with a solution of didecyldiethylammonium chloride 0.45% for 2 minutes to ensure complete sterilization. The calcification was then ultrasonographically visualized by using sterile lubricant contact gel (Glissen 12.5 g; Pharm Fabrik Montavit Ges.m.b.H., Absam, Germany). After ultrasound-guided local anesthesia injection (5 mL mepivacaine chlorhydrate 2% without PM&R 1934-1482/14/$36.00 Printed in U.S.A.
L.M.S. Servizio di Radiologia, IRCCS Policlinico San Donato; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Piazza Malan 2, 20097 San Donato Milanese, Milano, Italy. Address correspondence to: L.M.S.; e-mail: io@lucasconfienza.it Disclosure: nothing to disclose F.R. Unità Operativa di Chirurgia dell’Anca, IRCCS Policlinico San Donato, Milano, Italy Disclosure: nothing to disclose S.S. Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Milano, Italy Disclosure: nothing to disclose F.S. Servizio di Radiologia, IRCCS Policlinico San Donato, Milano, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy Disclosure: nothing to disclose P.R. Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy; Unità Operativa di Chirurgia della Spalla, IRCCS Policlinico San Donato, Milano, Italy Disclosure: nothing to disclose Submitted for publication October 12, 2013; accepted January 5, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. -, 1-3, - 2014 http://dx.doi.org/10.1016/j.pmrj.2014.01.004
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166 167 168 169 170 171 172 Q4173 174 175 176 177 178 179 Figure 1. The appearance of a calcific deposit at the end of Q5180 lavage procedure using a single needle (arrows); the calcific 181 deposit within the supraspinatus tendon (SST) is completely 182 empty (asterisks), and only a thin peripheral rim (arrowheads) is 183 visible; the subacromial bursa (circles) is distended by anesthetic fluid. A ¼ acromion; H ¼ humeral head. 184 185 186 187 adrenaline) into the subacromial-subdeltoid bursa, the 188 subcutaneous tissues, and around the calcification, one 189 16-gauge needle was inserted inside the calcification under 190 continuous ultrasound monitoring. A 20-mL syringe of 42 C 191 saline solution (NaCl 0.9%) was connected to the needle, 192 and the plunger was gently pushed and released several 193 times to obtain calcium retrieval directly within the syringe 194 [3]. This step was repeated a number of times until the fluid 195 flush was completely free of visible calcium (Figure 1). Once 196 the washing phase was completed, the needle was flushed 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 Figure 2. (A) Arthroscopic evaluation of the subacromial space; whitish material (arrows) can be seen in the anterior recess; this 218 material was considered to be pus consistent with infection. (B) Arthroscopic evaluation of the joint space; no septic material can be 219 seen. H ¼ humeral head. 220 and then removed from the tendon; then, 1 mL of triamcinolone acetonide (Kenacort 40 mg/mL; Bristol-Myers Squibb, Italy) was injected within the subacromial-subdeltoid bursa under direct ultrasound guidance. The skin was cleaned again, and a bandage and ice were applied over the treated shoulder. The patient was observed for approximately 30 minutes and then discharged. After 4 days, the patient contacted the radiologist who had performed the procedure and reported malaise and the occurrence of increasing shoulder pain since 2 days after the procedure. He was admitted to the emergency department of our institution within a few hours. Visual inspection of the shoulder revealed no signs of local inflammation. Body temperature was 37.9 C. Results of a blood test revealed a white blood cell count of 14,720 (reference range, 400011,000) and C-reactive protein equal to 8.2 mg/dL (reference value, <0.5 mg/dL). A limited ultrasound evaluation revealed the presence of thickened subacromial-subdeltoid bursa, which contained a layer of hypoechoic corpuscular fluid (image not available). Under ultrasound guidance, the bursa was punctured and approximately 1 mL of yellowish, pus-like fluid was drained. This fluid was sent for examination; however, the laboratory did not accept the ultrasound-guided aspirate due to contamination. Intravenous administration of antibiotic drugs (ciprofloxacin and teicoplanin) was immediately started. The patient was then admitted to the hospital and underwent arthroscopy the next day. Arthroscopy had the purpose of performing a thorough washing of the subacromial space and glenohumeral joint. The patient was placed in lateral decubitus position with the arm in traction,
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and the arthroscopy was started first in the subacromial space to avoid any dissemination of the possible infection in the glenohumeral joint. Arthroscopic evaluation showed the presence of whitish-yellowish material in the subacromial space. This material was considered pus consistent with infection. It was collected and sent to the laboratory to be screened for bacteria. The subacromial bursa was clearly inflamed. The bursa was completely removed with a shaver blade, and then the rotator cuff and subacromial space were thoroughly washed with 15 L of normal saline solution. Finally, the glenohumeral joint was inspected and showed no sign of infection or inflammation. A sample of fluid from the glenohumeral joint was harvested and sent to the laboratory for microbiologic testing. The arthroscopic evaluation of subacromial and joint spaces is shown in Figure 2. The patient was kept in the hospital for 2 days after the arthroscopy and was then discharged. Ten days after surQ6 gery, the white blood cell count was 8400 and C-reactive protein was 0.6 mg/dL. A microbiologic analysis revealed that the subacromial space was infected with Staphylococcus capitis. No infection was found in the joint space.
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In all published studies dealing with ultrasound-guided percutaneous treatment of rotator cuff calcific tendinopathy, a small dose of low-solubility steroid is injected in the subacromial-subdeltoid bursa after the procedure [1-7]. This has the purpose of facilitating postprocedural pain reduction. The steroid can then further lower the local immune response [9]. Also, to reach the calcium deposit, the bursa sac is violated, thus risking introduction of infection. This may have happened in our patient. However, a similar event has not been previously described in the literature [1-7].
CONCLUSION We report the first case of septic bursitis after ultrasoundguided percutaneous treatment of calcific tendinopathy of the rotator cuff. Although generally considered a very safe procedure, the risk of infection should always be taken into account. Further studies should evaluate whether intrabursal steroid injection after this procedure is necessary or whether alternative postprocedure pain control methods (eg, hyaluronic acid injection, oral pain-killer administration) could be used [10].
DISCUSSION We report the first case, to our knowledge, of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy of the rotator cuff. This procedure is generally considered safe and is normally performed in our outpatient radiology clinic by using standard antiseptic procedures [1-7]. We always interview our patients to screen for the presence of known pre-existing conditions that may increase the complication rate or contraindicate the procedure of calcification removal, such as diabetes, coagulopathies, or allergies. However, we do not perform specific blood tests before ultrasound-guided calcification removal. In this case, the patient declared no illnesses. In the 2 largest series of patients who underwent ultrasound-guided treatment of calcific tendinopathy [1,2], complications were limited to mild vagal reaction during the procedure in up to 5.1% of patients and postprocedural bursitis in up to 13.1% of cases. In other series, complications were not clearly reported or were also limited to mild pain after the procedure [1-7]. However, all of those should be regarded as minor complications. Staphylococcus capitis is a coagulase-negative bacterium that is generally part of the normal flora of the skin and of the oral mucosa [8]. Thus, the most probable cause of infection was a failure in the sterilization process of the skin or of the probe, despite the fact that our protocol is fairly standardized and is repeated several times during the day. Also, we are not able to recall any particular event during the treatment that could have led to inaccurate skin cleaning.
REFERENCES 1. Serafini G, Sconfienza LM, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: Short-term and 10-year outcomes after two-needle US-guided percutaneous treatment— nonrandomized controlled trial. Radiology 2009;252:157-164. 2. Sconfienza LM, Bandirali M, Serafini G, et al. Rotator cuff calcific tendinitis: Does warm saline solution improve the short-term outcome of double-needle US-guided treatment? Radiology 2012;262:560-566. 3. Sconfienza LM, Viganò S, Martini C, et al. Double-needle ultrasoundguided percutaneous treatment of rotator cuff calcific tendinitis: Tips and tricks. Skelet Radiol 2013;42:19-24. 4. Fabbro E, Ferrero G, Orlandi D, et al. Rotator cuff ultrasound-guided procedures: Technical and outcome improvements. Imaging Med 2012;4:649-656. 5. Aina R, Cardinal E, Bureau NJ, Aubin B, Brassard P. Calcific shoulder tendinitis: Treatment with modified US-guided fine-needle technique. Radiology 2001;221:455-461. 6. Orlandi D, Fabbro E, Mauri G, Savarino E, Serafini G, Sconfienza LM. RE: A simple technique to restore needle patency during percutaneous lavage and aspiration of calcific rotator cuff tendinopathy. PM R 2013; 5:633. 7. Jelsing EJ, Maida E, Smith J. A simple technique to restore needle patency during percutaneous lavage and aspiration of calcific rotator cuff tendinopathy. PM R 2013;5:242-244. 8. Brook I. Secondary bacterial infections complicating skin lesions. J Med Microbiol 2002;51:808-812. 9. Brinks A, Koes BW, Volkers AC, Verhaar JA, Bierma-Zeinstra SM. Adverse effects of extra-articular corticosteroid injections: A systematic review. BMC Musculoskelet Disord 2010;11:206. 10. Tagliafico A, Serafini G, Sconfienza LM, et al. Ultrasound-guided viscosupplementation of subacromial space in elderly patients with cuff tear arthropathy using a high weight hyaluronic acid: Prospective openlabel non-randomized trial. Eur Radiol 2011;21:182-187.
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Septic Bursitis After Ultrasound-guided Percutaneous Treatment of Rotator Cuff Calcific Tendinopathy Q7 Q1
Luca Maria Sconfienza, MD, PhD, Filippo Randelli, Silvana Sdao, Francesco Sardanelli, Pietro Randelli Calcific tendinopathy of the rotator cuff is a common condition. Ultrasound-guided percutaneous aspiration is one of several options to treat this condition. The main advantages of this procedure are short duration, good outcome, and low cost. Furthermore, only minor complications have been reported in the literature, namely, vagal reactions during the procedure and mild postprocedural pain. We report the first case of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy. Although this is generally considered a very safe procedure, a risk of infection should be taken into account. PM R 2014;-:1-3
INTRODUCTION
Q2
Calcific tendinopathy of the rotator cuff is a common condition [1]. Intratendinous calcifications can be found in up to 7.5% of asymptomatic shoulders and in up to 20% of painful shoulders [1,2]. When symptomatic, calcific tendinopathy can be very painful and disabling for patients, thus requiring prompt treatment. Several options have been proposed to treat this condition [1-4]; currently, ultrasound-guided percutaneous aspiration is one treatment option [5,6]. This procedure can be performed with a number of approaches. The main difference among these approaches is the use of 1 or 2 needles to aspirate calcium under ultrasound guidance [1-5]. The main advantages of these procedures are the short duration, the good short- and long-term outcomes, and the relatively low cost [1-7]. Furthermore, only minor complications have been reported, namely vagal reactions during the procedure and mild postprocedural pain [1-7]. We report the first case, to our knowledge, of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy of the rotator cuff.
CASE PRESENTATION
Q3
A 44-year-old male patient was referred to our radiology clinic for aspiration therapy for a 22-mm intratendinous calcium deposit in the right supraspinatus tendon. He reported moderate pain that lasted for approximately 6 months that was associated with limitation in abduction movement of his right arm. The patient was in good health, with no known condition that would contraindicate the aspiration procedure. The injection area was prepared according to standard sterile protocol [1,2]. With the patient lying supine on the bed, the skin was cleaned with a solution of iodopovidone 10% for 2 minutes and then cleaned again with benzalkonium chloride 0.25% solution to ensure complete sterilization and to avoid probe staining. Sterile drapes were subsequently applied. The ultrasound probe (6- to 13-MHz high-resolution broadband linear array transducer and MyLab 70 XvG ultrasound system; Esaote, Genova, Italy) was thoroughly cleaned with a solution of didecyldiethylammonium chloride 0.45% for 2 minutes to ensure complete sterilization. The calcification was then ultrasonographically visualized by using sterile lubricant contact gel (Glissen 12.5 g; Pharm Fabrik Montavit Ges.m.b.H., Absam, Germany). After ultrasound-guided local anesthesia injection (5 mL mepivacaine chlorhydrate 2% without PM&R 1934-1482/14/$36.00 Printed in U.S.A.
L.M.S. Servizio di Radiologia, IRCCS Policlinico San Donato; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Piazza Malan 2, 20097 San Donato Milanese, Milano, Italy. Address correspondence to: L.M.S.; e-mail: io@lucasconfienza.it Disclosure: nothing to disclose F.R. Unità Operativa di Chirurgia dell’Anca, IRCCS Policlinico San Donato, Milano, Italy Disclosure: nothing to disclose S.S. Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Milano, Italy Disclosure: nothing to disclose F.S. Servizio di Radiologia, IRCCS Policlinico San Donato, Milano, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy Disclosure: nothing to disclose P.R. Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy; Unità Operativa di Chirurgia della Spalla, IRCCS Policlinico San Donato, Milano, Italy Disclosure: nothing to disclose Submitted for publication October 12, 2013; accepted January 5, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. -, 1-3, - 2014 http://dx.doi.org/10.1016/j.pmrj.2014.01.004
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166 167 168 169 170 171 172 Q4173 174 175 176 177 178 179 Figure 1. The appearance of a calcific deposit at the end of Q5180 lavage procedure using a single needle (arrows); the calcific 181 deposit within the supraspinatus tendon (SST) is completely 182 empty (asterisks), and only a thin peripheral rim (arrowheads) is 183 visible; the subacromial bursa (circles) is distended by anesthetic fluid. A ¼ acromion; H ¼ humeral head. 184 185 186 187 adrenaline) into the subacromial-subdeltoid bursa, the 188 subcutaneous tissues, and around the calcification, one 189 16-gauge needle was inserted inside the calcification under 190 continuous ultrasound monitoring. A 20-mL syringe of 42 C 191 saline solution (NaCl 0.9%) was connected to the needle, 192 and the plunger was gently pushed and released several 193 times to obtain calcium retrieval directly within the syringe 194 [3]. This step was repeated a number of times until the fluid 195 flush was completely free of visible calcium (Figure 1). Once 196 the washing phase was completed, the needle was flushed 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 Figure 2. (A) Arthroscopic evaluation of the subacromial space; whitish material (arrows) can be seen in the anterior recess; this 218 material was considered to be pus consistent with infection. (B) Arthroscopic evaluation of the joint space; no septic material can be 219 seen. H ¼ humeral head. 220 and then removed from the tendon; then, 1 mL of triamcinolone acetonide (Kenacort 40 mg/mL; Bristol-Myers Squibb, Italy) was injected within the subacromial-subdeltoid bursa under direct ultrasound guidance. The skin was cleaned again, and a bandage and ice were applied over the treated shoulder. The patient was observed for approximately 30 minutes and then discharged. After 4 days, the patient contacted the radiologist who had performed the procedure and reported malaise and the occurrence of increasing shoulder pain since 2 days after the procedure. He was admitted to the emergency department of our institution within a few hours. Visual inspection of the shoulder revealed no signs of local inflammation. Body temperature was 37.9 C. Results of a blood test revealed a white blood cell count of 14,720 (reference range, 400011,000) and C-reactive protein equal to 8.2 mg/dL (reference value, <0.5 mg/dL). A limited ultrasound evaluation revealed the presence of thickened subacromial-subdeltoid bursa, which contained a layer of hypoechoic corpuscular fluid (image not available). Under ultrasound guidance, the bursa was punctured and approximately 1 mL of yellowish, pus-like fluid was drained. This fluid was sent for examination; however, the laboratory did not accept the ultrasound-guided aspirate due to contamination. Intravenous administration of antibiotic drugs (ciprofloxacin and teicoplanin) was immediately started. The patient was then admitted to the hospital and underwent arthroscopy the next day. Arthroscopy had the purpose of performing a thorough washing of the subacromial space and glenohumeral joint. The patient was placed in lateral decubitus position with the arm in traction,
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and the arthroscopy was started first in the subacromial space to avoid any dissemination of the possible infection in the glenohumeral joint. Arthroscopic evaluation showed the presence of whitish-yellowish material in the subacromial space. This material was considered pus consistent with infection. It was collected and sent to the laboratory to be screened for bacteria. The subacromial bursa was clearly inflamed. The bursa was completely removed with a shaver blade, and then the rotator cuff and subacromial space were thoroughly washed with 15 L of normal saline solution. Finally, the glenohumeral joint was inspected and showed no sign of infection or inflammation. A sample of fluid from the glenohumeral joint was harvested and sent to the laboratory for microbiologic testing. The arthroscopic evaluation of subacromial and joint spaces is shown in Figure 2. The patient was kept in the hospital for 2 days after the arthroscopy and was then discharged. Ten days after surQ6 gery, the white blood cell count was 8400 and C-reactive protein was 0.6 mg/dL. A microbiologic analysis revealed that the subacromial space was infected with Staphylococcus capitis. No infection was found in the joint space.
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2014
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In all published studies dealing with ultrasound-guided percutaneous treatment of rotator cuff calcific tendinopathy, a small dose of low-solubility steroid is injected in the subacromial-subdeltoid bursa after the procedure [1-7]. This has the purpose of facilitating postprocedural pain reduction. The steroid can then further lower the local immune response [9]. Also, to reach the calcium deposit, the bursa sac is violated, thus risking introduction of infection. This may have happened in our patient. However, a similar event has not been previously described in the literature [1-7].
CONCLUSION We report the first case of septic bursitis after ultrasoundguided percutaneous treatment of calcific tendinopathy of the rotator cuff. Although generally considered a very safe procedure, the risk of infection should always be taken into account. Further studies should evaluate whether intrabursal steroid injection after this procedure is necessary or whether alternative postprocedure pain control methods (eg, hyaluronic acid injection, oral pain-killer administration) could be used [10].
DISCUSSION We report the first case, to our knowledge, of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy of the rotator cuff. This procedure is generally considered safe and is normally performed in our outpatient radiology clinic by using standard antiseptic procedures [1-7]. We always interview our patients to screen for the presence of known pre-existing conditions that may increase the complication rate or contraindicate the procedure of calcification removal, such as diabetes, coagulopathies, or allergies. However, we do not perform specific blood tests before ultrasound-guided calcification removal. In this case, the patient declared no illnesses. In the 2 largest series of patients who underwent ultrasound-guided treatment of calcific tendinopathy [1,2], complications were limited to mild vagal reaction during the procedure in up to 5.1% of patients and postprocedural bursitis in up to 13.1% of cases. In other series, complications were not clearly reported or were also limited to mild pain after the procedure [1-7]. However, all of those should be regarded as minor complications. Staphylococcus capitis is a coagulase-negative bacterium that is generally part of the normal flora of the skin and of the oral mucosa [8]. Thus, the most probable cause of infection was a failure in the sterilization process of the skin or of the probe, despite the fact that our protocol is fairly standardized and is repeated several times during the day. Also, we are not able to recall any particular event during the treatment that could have led to inaccurate skin cleaning.
REFERENCES 1. Serafini G, Sconfienza LM, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: Short-term and 10-year outcomes after two-needle US-guided percutaneous treatment— nonrandomized controlled trial. Radiology 2009;252:157-164. 2. Sconfienza LM, Bandirali M, Serafini G, et al. Rotator cuff calcific tendinitis: Does warm saline solution improve the short-term outcome of double-needle US-guided treatment? Radiology 2012;262:560-566. 3. Sconfienza LM, Viganò S, Martini C, et al. Double-needle ultrasoundguided percutaneous treatment of rotator cuff calcific tendinitis: Tips and tricks. Skelet Radiol 2013;42:19-24. 4. Fabbro E, Ferrero G, Orlandi D, et al. Rotator cuff ultrasound-guided procedures: Technical and outcome improvements. Imaging Med 2012;4:649-656. 5. Aina R, Cardinal E, Bureau NJ, Aubin B, Brassard P. Calcific shoulder tendinitis: Treatment with modified US-guided fine-needle technique. Radiology 2001;221:455-461. 6. Orlandi D, Fabbro E, Mauri G, Savarino E, Serafini G, Sconfienza LM. RE: A simple technique to restore needle patency during percutaneous lavage and aspiration of calcific rotator cuff tendinopathy. PM R 2013; 5:633. 7. Jelsing EJ, Maida E, Smith J. A simple technique to restore needle patency during percutaneous lavage and aspiration of calcific rotator cuff tendinopathy. PM R 2013;5:242-244. 8. Brook I. Secondary bacterial infections complicating skin lesions. J Med Microbiol 2002;51:808-812. 9. Brinks A, Koes BW, Volkers AC, Verhaar JA, Bierma-Zeinstra SM. Adverse effects of extra-articular corticosteroid injections: A systematic review. BMC Musculoskelet Disord 2010;11:206. 10. Tagliafico A, Serafini G, Sconfienza LM, et al. Ultrasound-guided viscosupplementation of subacromial space in elderly patients with cuff tear arthropathy using a high weight hyaluronic acid: Prospective openlabel non-randomized trial. Eur Radiol 2011;21:182-187.
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