- Email: [email protected]
Intra-Articular or Juxta-Articular?
965
LETTERS TO THE EDITOR
Intra-Articular or Juxta-Articular?
The Author Responds 1
I read the recent article by Lee et al, “Randomized Controlled Trial for Efficacy of Intra-Articular Injection for Adhesive Capsulitis: Ultrasonography-Guided Versus Blind Technique,” with great interest. I congratulate the authors for the excellent comparative study between ultrasonography (US)– guided and blind techniques for the treatment of adhesive capsulitis. There are, however, some issues in the article that deserve further comment. The first has to do with the US-guided needling method. Currently, 2 dominant techniques are being used for this procedure.2 One is the out-of-plane technique, which involves inserting a needle across the plane of imaging near the target. The other is the in-plane technique, which involves inserting a needle within the plane of imaging to visualize the entire shaft and tip. Both techniques have their merits and limitations. The in-plane technique allows the entire needle path to be shown, but it is time-consuming and requires a lot of experience. Lee1 stated that the approach suggested by Yi et al3 was used. Figures 2 and 3 in Yi’s3 article show the out-of-plane technique. However, figure 1 in Lee’s1 article shows the in-plane technique. The second issue is the conformation of the intra-articular injection. To date, arthrography has been considered the imaging criterion standard after intra-articular injection of the contrast material. Yi3 also performed arthrography to confirm the contrast material in the joint capsule after US-guided intraarticular injection. However, Lee1 only verified the expansion of the articular capsule during the US-guided injection without arthrography. From figure 2 in the paper by Lee,1 it appears that the distension of the capsular joint is not significant; furthermore, the shaft and tip of the needle cannot be seen, putting the result of the in-plane technique in doubt. Moreover, the saline volume of 4mL stated in the Abstract is not consistent with that of 3mL stated in the Methods section in the article.
I appreciate the reader’s interest on my article.1 In his letter, Paik made several queries, to which I respond below. First, Paik commented that there are 2 techniques for ultrasonography (US)– guided injection: an in-plane technique, which involves inserting a needle within the plane of imaging to visualize the entire shaft and tip of the needle, and an out-plane technique, which involves inserting a needle across the plane of imaging near the target.2 Also, he pointed out correctly that our group used the in-plane technique, while Yi et al3 used the out-plane technique, which I omitted to mention, unfortunately. So, as Paik pointed out, our procedure, in detail, is as follows. We used the in-plane technique, which involves inserting a needle within the plane of imaging to visualize the entire shaft and tip of the needle. However, I cited the article by Yi3 because both groups used the same posterior approach for the intra-articular injection. Second, Paik mentioned that we did not show data for accuracy of intra-articular injection in these 2 techniques. My concern was the actual clinical outcomes and their weekly changes after the 2 injection techniques. As mentioned in the study by Yi,3 the accuracy of blind technique is below 50%, and that of the US-guided technique is almost 100%. We did not intend to measure again the accuracy of the intra-articular injection of these 2 techniques. Third, Paik doubted the verification of the photo for intraarticular injection with US guidance in figure 2. We definitely confirmed the capsular expansion and positioning of the needle tip during the procedure. The reason you cannot see the shaft and tip of the needle in the photo is that we had a problem with resolution of the photo while storing it as a picture file in my US equipment. A better quality photo could have shown the shaft and tip of the needle. Finally, Paik was correct in noting that the volume of saline for the triamcinolone injection was different in the Abstract and the Methods. I apologize for this. The actual amount of saline was 3mL as shown in the Methods.
Nam Chull Paik, MD Department of Radiology Arumdaun Wooldul Spine Hospital Ulsan, Republic of Korea
Hong-Jae Lee, MD Department of Physical Medicine and Rehabilitation Inje Universtiy Ilsanpaik Hospital, South Korea
Disclosure: No commercial party having a direct financial interest in the results of the research supporting this letter has or will confer a benefit on the authors or on any organization with which the authors are associated.
Disclosure: No commercial party having a direct financial interest in the results of the research supporting this letter has or will confer a benefit on the authors or on any organization with which the authors are associated.
References 1. Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002. 2. Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology 2006;104:368-73. 3. Yi TI, Kim ST, Kim DH, Kim JS, Park JS, Lee JH. Comparison of blind technique and ultrasonography guided technique of intraarticular injection of the shoulder. J Korean Acad Rehabil Med 2006;30:45-50.
References 1. Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002. 2. Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology 2006;104:368-73. 3. Yi TI, Kim ST, Kim DH, Kim JS, Park JS, Lee JH. Comparison of blind technique and ultrasonography guided technique of intraarticular injection of the shoulder. J Korean Acad Rehabil Med 2006;30:45-50.
doi:10.1016/j.apmr.2010.03.010
doi:10.1016/j.apmr.2010.03.011
Arch Phys Med Rehabil Vol 91, June 2010
LETTERS TO THE EDITOR
Intra-Articular or Juxta-Articular?
The Author Responds 1
I read the recent article by Lee et al, “Randomized Controlled Trial for Efficacy of Intra-Articular Injection for Adhesive Capsulitis: Ultrasonography-Guided Versus Blind Technique,” with great interest. I congratulate the authors for the excellent comparative study between ultrasonography (US)– guided and blind techniques for the treatment of adhesive capsulitis. There are, however, some issues in the article that deserve further comment. The first has to do with the US-guided needling method. Currently, 2 dominant techniques are being used for this procedure.2 One is the out-of-plane technique, which involves inserting a needle across the plane of imaging near the target. The other is the in-plane technique, which involves inserting a needle within the plane of imaging to visualize the entire shaft and tip. Both techniques have their merits and limitations. The in-plane technique allows the entire needle path to be shown, but it is time-consuming and requires a lot of experience. Lee1 stated that the approach suggested by Yi et al3 was used. Figures 2 and 3 in Yi’s3 article show the out-of-plane technique. However, figure 1 in Lee’s1 article shows the in-plane technique. The second issue is the conformation of the intra-articular injection. To date, arthrography has been considered the imaging criterion standard after intra-articular injection of the contrast material. Yi3 also performed arthrography to confirm the contrast material in the joint capsule after US-guided intraarticular injection. However, Lee1 only verified the expansion of the articular capsule during the US-guided injection without arthrography. From figure 2 in the paper by Lee,1 it appears that the distension of the capsular joint is not significant; furthermore, the shaft and tip of the needle cannot be seen, putting the result of the in-plane technique in doubt. Moreover, the saline volume of 4mL stated in the Abstract is not consistent with that of 3mL stated in the Methods section in the article.
I appreciate the reader’s interest on my article.1 In his letter, Paik made several queries, to which I respond below. First, Paik commented that there are 2 techniques for ultrasonography (US)– guided injection: an in-plane technique, which involves inserting a needle within the plane of imaging to visualize the entire shaft and tip of the needle, and an out-plane technique, which involves inserting a needle across the plane of imaging near the target.2 Also, he pointed out correctly that our group used the in-plane technique, while Yi et al3 used the out-plane technique, which I omitted to mention, unfortunately. So, as Paik pointed out, our procedure, in detail, is as follows. We used the in-plane technique, which involves inserting a needle within the plane of imaging to visualize the entire shaft and tip of the needle. However, I cited the article by Yi3 because both groups used the same posterior approach for the intra-articular injection. Second, Paik mentioned that we did not show data for accuracy of intra-articular injection in these 2 techniques. My concern was the actual clinical outcomes and their weekly changes after the 2 injection techniques. As mentioned in the study by Yi,3 the accuracy of blind technique is below 50%, and that of the US-guided technique is almost 100%. We did not intend to measure again the accuracy of the intra-articular injection of these 2 techniques. Third, Paik doubted the verification of the photo for intraarticular injection with US guidance in figure 2. We definitely confirmed the capsular expansion and positioning of the needle tip during the procedure. The reason you cannot see the shaft and tip of the needle in the photo is that we had a problem with resolution of the photo while storing it as a picture file in my US equipment. A better quality photo could have shown the shaft and tip of the needle. Finally, Paik was correct in noting that the volume of saline for the triamcinolone injection was different in the Abstract and the Methods. I apologize for this. The actual amount of saline was 3mL as shown in the Methods.
Nam Chull Paik, MD Department of Radiology Arumdaun Wooldul Spine Hospital Ulsan, Republic of Korea
Hong-Jae Lee, MD Department of Physical Medicine and Rehabilitation Inje Universtiy Ilsanpaik Hospital, South Korea
Disclosure: No commercial party having a direct financial interest in the results of the research supporting this letter has or will confer a benefit on the authors or on any organization with which the authors are associated.
Disclosure: No commercial party having a direct financial interest in the results of the research supporting this letter has or will confer a benefit on the authors or on any organization with which the authors are associated.
References 1. Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002. 2. Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology 2006;104:368-73. 3. Yi TI, Kim ST, Kim DH, Kim JS, Park JS, Lee JH. Comparison of blind technique and ultrasonography guided technique of intraarticular injection of the shoulder. J Korean Acad Rehabil Med 2006;30:45-50.
References 1. Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002. 2. Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology 2006;104:368-73. 3. Yi TI, Kim ST, Kim DH, Kim JS, Park JS, Lee JH. Comparison of blind technique and ultrasonography guided technique of intraarticular injection of the shoulder. J Korean Acad Rehabil Med 2006;30:45-50.
doi:10.1016/j.apmr.2010.03.010
doi:10.1016/j.apmr.2010.03.011
Arch Phys Med Rehabil Vol 91, June 2010