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Do we still need to take fluoroscopical guidance into account when injecting joints?
Seminars in Arthritis and Rheumatism ] (2016) ]]]–]]]
Contents lists available at ScienceDirect
Seminars in Arthritis and Rheumatism journal homepage: www.elsevier.com/locate/semarthrit
Do we still need to take fluoroscopical guidance into account when injecting joints? Dear Sirs, We read with great interest the article by Henrotin and colleagues entitled “Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis” published some months ago in Seminars in Arthritis and Rheumatism [1]. The topic is of paramount importance in the current management of osteoarthritis and the article addresses it in very high detail. However, we are concerned about the message reported about the potential use of ionizing radiations to perform intrarticular injections. Authors state that imaging guidance should be used “as often as possible, according to the technical capabilities of the physician,” thus they declare to be unable to provide advice on the type of guidance to use. In chapter VII of the recent directive 2013/59/ issued by the European Atomic Energy Community (EURATOM), which is an update of the old 97/43/ EURATOM directive, it is clearly stated that exposure to ionizing radiations should “take into account the efficacy, benefits, and risks of available alternative techniques having the same objective but involving no or less exposure to ionizing radiation” [2]. This means that ionizing radiations (i.e., fluoroscopy) shall not be used if other imaging modalities not using ionizing radiations (i.e., ultrasound) can be used with the same effect. Authors very well recalled that there is no real difference of injection accuracy between procedures performed under ultrasound or fluoroscopy guidance. Also, the advantages of ultrasound were extensively reviewed in a recent article published in European Radiology, in which the authors concluded that US represents an easy, cheap, effective, and radiation-free imaging modality to perform interventional procedures in the musculoskeletal system [3]. The article of Henrotin et al. simply refers to EURATOM directive, but in light of the many advantages of ultrasound, we believe this aspect should be stressed to the uttermost. This is of paramount importance when injecting the shoulder and the hip. Although patients undergoing injections for viscosupplementation purposes are usually elderly individuals, irradiation invariably occurs over very sensitive organs, such as the thyroid and the gonads, respectively. Of note, as stated by a report of United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) issued in 2008, the arthrography average effective dose of is 0.17 mSv, a value that is nearly 10 times higher than a posteroanterior chest x-ray, which average effective dose is 0.02 mSv [4,5]. A similar dose is expected also when injections are performed for therapeutic purposes under fluoroscopic guidance. Furthermore, the use of iodinated contrast to confirm the position of the needle, not only may dilute the viscosupplementant, potentially diminishing the efficacy of the procedure, but increases http://dx.doi.org/10.1016/j.semarthrit.2016.08.005 0049-0172/& 2016 Elsevier Inc. All rights reserved.
costs and may also lead to iodine-induced allergic reactions, especially in subjects undergoing multiple administration [1,3]. For what above recalled, we really cannot see any good reason why fluoroscopy should be still used to inject joints, except the mere preference of the performing physician. Thus, the medical and scientific community should promote specific educational courses both to raise the awareness on risks of ionizing radiations and to implement the practical use of dedicated ultrasound systems to perform these procedures. Carmelo Messina, MDa,n Scuola di Specializzazione in Radiodiagnostica Universita` degli Studi di Milano via Festa del Perdono, 7 Milano 20122, Italy E-mail address: [email protected] (C. Messina) a
Luca M. Sconfienza, MD, PhDb,c Radiologia/Diagnostica per Immagini con Servizio di Radiologia Interventistica IRCCS Istituto Ortopedico Galeazzi Via Riccardo Galeazzi, 4 20161 Milano, Italy c Dipartimento di Scienze Biomediche per la Salute Universita` degli Studi di Milano, Via Carlo Pascal 36, 20133 Milano, Italy b
References [1] Henrotin Y, Raman R, Richette P, Bard H, Jerosch J, Conrozier T, et al. Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis. Semin Arthritis Rheum 2015;45:140–9, http://dx.doi.org/ 10.1016/j.semarthrit.2015.04.011. [2] European Commission. 2013/59/EURATOM directive. 〈http://eur-lex.europa.eu/ legal-content/EN/TXT/?uri=uriserv:OJ.L_.2014.013.01.0001.01.ENG〉; n.d. [accessed 11.05.16]. [3] Messina C, Banfi G, Aliprandi A, Mauri G, Secchi F, Sardanelli F, et al. Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now. Eur Radiol 2016;26:1221–5, http://dx.doi.org/10.1007/ s00330-015-3945-3. [4] United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation. Report, vol. 1. p. 76. 〈http://www.unscear.org/ docs/reports/2008/09-86753_Report_2008_Annex_A.pdf〉; 2008 [accessed 11.05.16]. [5] Mettler FA, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008;248:254–63, http://dx. doi.org/10.1148/radiol.2481071451.
n
Corresponding author.
Contents lists available at ScienceDirect
Seminars in Arthritis and Rheumatism journal homepage: www.elsevier.com/locate/semarthrit
Do we still need to take fluoroscopical guidance into account when injecting joints? Dear Sirs, We read with great interest the article by Henrotin and colleagues entitled “Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis” published some months ago in Seminars in Arthritis and Rheumatism [1]. The topic is of paramount importance in the current management of osteoarthritis and the article addresses it in very high detail. However, we are concerned about the message reported about the potential use of ionizing radiations to perform intrarticular injections. Authors state that imaging guidance should be used “as often as possible, according to the technical capabilities of the physician,” thus they declare to be unable to provide advice on the type of guidance to use. In chapter VII of the recent directive 2013/59/ issued by the European Atomic Energy Community (EURATOM), which is an update of the old 97/43/ EURATOM directive, it is clearly stated that exposure to ionizing radiations should “take into account the efficacy, benefits, and risks of available alternative techniques having the same objective but involving no or less exposure to ionizing radiation” [2]. This means that ionizing radiations (i.e., fluoroscopy) shall not be used if other imaging modalities not using ionizing radiations (i.e., ultrasound) can be used with the same effect. Authors very well recalled that there is no real difference of injection accuracy between procedures performed under ultrasound or fluoroscopy guidance. Also, the advantages of ultrasound were extensively reviewed in a recent article published in European Radiology, in which the authors concluded that US represents an easy, cheap, effective, and radiation-free imaging modality to perform interventional procedures in the musculoskeletal system [3]. The article of Henrotin et al. simply refers to EURATOM directive, but in light of the many advantages of ultrasound, we believe this aspect should be stressed to the uttermost. This is of paramount importance when injecting the shoulder and the hip. Although patients undergoing injections for viscosupplementation purposes are usually elderly individuals, irradiation invariably occurs over very sensitive organs, such as the thyroid and the gonads, respectively. Of note, as stated by a report of United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) issued in 2008, the arthrography average effective dose of is 0.17 mSv, a value that is nearly 10 times higher than a posteroanterior chest x-ray, which average effective dose is 0.02 mSv [4,5]. A similar dose is expected also when injections are performed for therapeutic purposes under fluoroscopic guidance. Furthermore, the use of iodinated contrast to confirm the position of the needle, not only may dilute the viscosupplementant, potentially diminishing the efficacy of the procedure, but increases http://dx.doi.org/10.1016/j.semarthrit.2016.08.005 0049-0172/& 2016 Elsevier Inc. All rights reserved.
costs and may also lead to iodine-induced allergic reactions, especially in subjects undergoing multiple administration [1,3]. For what above recalled, we really cannot see any good reason why fluoroscopy should be still used to inject joints, except the mere preference of the performing physician. Thus, the medical and scientific community should promote specific educational courses both to raise the awareness on risks of ionizing radiations and to implement the practical use of dedicated ultrasound systems to perform these procedures. Carmelo Messina, MDa,n Scuola di Specializzazione in Radiodiagnostica Universita` degli Studi di Milano via Festa del Perdono, 7 Milano 20122, Italy E-mail address: [email protected] (C. Messina) a
Luca M. Sconfienza, MD, PhDb,c Radiologia/Diagnostica per Immagini con Servizio di Radiologia Interventistica IRCCS Istituto Ortopedico Galeazzi Via Riccardo Galeazzi, 4 20161 Milano, Italy c Dipartimento di Scienze Biomediche per la Salute Universita` degli Studi di Milano, Via Carlo Pascal 36, 20133 Milano, Italy b
References [1] Henrotin Y, Raman R, Richette P, Bard H, Jerosch J, Conrozier T, et al. Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis. Semin Arthritis Rheum 2015;45:140–9, http://dx.doi.org/ 10.1016/j.semarthrit.2015.04.011. [2] European Commission. 2013/59/EURATOM directive. 〈http://eur-lex.europa.eu/ legal-content/EN/TXT/?uri=uriserv:OJ.L_.2014.013.01.0001.01.ENG〉; n.d. [accessed 11.05.16]. [3] Messina C, Banfi G, Aliprandi A, Mauri G, Secchi F, Sardanelli F, et al. Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now. Eur Radiol 2016;26:1221–5, http://dx.doi.org/10.1007/ s00330-015-3945-3. [4] United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation. Report, vol. 1. p. 76. 〈http://www.unscear.org/ docs/reports/2008/09-86753_Report_2008_Annex_A.pdf〉; 2008 [accessed 11.05.16]. [5] Mettler FA, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008;248:254–63, http://dx. doi.org/10.1148/radiol.2481071451.
n
Corresponding author.