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Musculoskeletal Intervention: Thinking Outside the Box
Volume 24
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Number 6
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June
’
2013
793
INVITED COMMENTARY
Musculoskeletal Intervention: Thinking Outside the Box Peter L. Munk, MDCM, FRCPC In its early years, interventional radiology was considered principally the domain of vascular radiologists. As the subspecialty evolved, biliary and gastrointestinal intervention, as well as general genitourinary intervention, formed an increasingly large part of interventional practices. During the past dozen years, musculoskeletal procedures have also come to have a higher profile, particularly with the advent of cement injection procedures and ablation technologies. Angiographic procedures dealing with the musculoskeletal system have principally been restricted to embolization procedures following trauma or in the treatment of tumors for preoperative devascularization or for treatment of vascular malformations. In a thought-provoking article, Okuno et al (1) describe their early experience with the use of transcatheter arterial embolization for treatment of recalcitrant tendinopathy and enthesopathy that had proven unresponsive to more traditional therapies. This is certainly a novel and unconventional approach to a ubiquitous problem: a rare example of vascular treatment of musculoskeletal disease outside of the aforemementioned usual three indications. Other purposes of embolization in the musculoskeletal system include the management of bleeding from synovitis (2–5). This can be seen in patients following total joint arthroplasty or in patients with hemophilia (4). Treatment of hemophiliac pseudotumors by embolization has also been described, and can be extremely helpful, particularly when pseudotumors are in surgically inaccessible sites (6–9). Tendinopathy/enthesopathy is an extremely common presenting symptom in patients, both young and old. Although certainly not life-threatening, these conditions affect quality of life and can have a major impact on the ability to work and play. Although a clear relationship does exist with overuse syndromes, the pathophysiology of these processes is extremely poorly understood and a matter of considerable debate. This lack of a clear understanding of the physiologic basis of this process is reflected in the vast From the Department of Radiology, University of British Columbia, Vancouver General Hospital and University of British Columbia Hospital, 899 West 12th Ave., Vancouver, BC, Canada V5Z 1M9. Received March 14, 2013; final revision received March 15, 2013; accepted March 15, 2013. Address correspondence to P.L.M.; E-mail: [email protected] & SIR, 2013 J Vasc Interv Radiol 2013; 24:793–794 http://dx.doi.org/10.1016/j.jvir.2013.03.016
array of different therapies used in treating this condition. These range from a variety of conservative measures involving stretching and physiotherapy, ice packs, as well as more invasive therapy involving injections of various substances. Injections have traditionally been performed with glucocorticoids, but have also been performed with other materials, such as autologous blood, platelet-enriched plasma (often admixed with activated thrombin), as well as ozone (10–14). Shockwave therapy has also been advocated, and a variety of surgical procedures, both arthroscopic and open, have been described for patients in whom the use of less invasive techniques has failed (15,16). The literature is replete with articles assessing these various therapies, and the conclusions of authors are at great variance. In short, the literature could probably accurately be described as a somewhat bewildering and confusing muddle. It seems that different patients respond to different therapies—probably at least in part a reflection of our poor understanding of the disease process and the ideal therapy (or therapies) in individual situations (17,18). Tendons and entheses are exposed to considerable stress and strain, as they are responsible for transmission of force between soft tissue and, ultimately, bone. These tissues tend to be hypocellular and generally are poorly vascularized. Yet, it has been noted that, when these structures are injured, there is often evidence of increased neovascularity, which has been extensively studied, particularly with colored Doppler ultrasound (17). Many therapies attempt to target this neovascularity and accompanying inflammation. Glucocorticoids would be an example of this, but many surgical procedures attempt to strip the highly vascularized tissues around these structures because this appears to produce relief of the patients’ symptoms. Injections of sclerosing agents are thought to potentially act by sclerosing this neovascularity. Other authorities claim that the use of agents such as hypertonic dextrose and platelet-enriched plasma can actually (at least in part) show an effect by producing irritation stimulating stem cells within the hypocellular tissues and inciting formation of fibroblasts, thereby activating repair of these damaged structures (10) Platelet-enriched plasma, in particular, is thought to act by introducing bioactive growth factors, thereby accelerating healing. At present, no one really knows for sure (11). Okuno et al (1) sought to treat the new vascularization associated with tendinopathy and enthesopathy with
794
’
Commentary: Musculoskeletal Intervention—Think Outside the Box
transarterial embolization. They deliberately selected an antibiotic particulate embolization agent (which I think is unfamiliar to most readers of this journal) with a very small particle diameter, as the new vascularity consists of tiny vessels. Their results were intriguing, as their patients’ conditions seemed to improve. Admittedly, this is something of a pilot project, as a small number of patients was treated in a wide variety of different anatomic sites. Neither I, nor, I think, the authors (1), would advocate the use of this treatment modality routinely without further evaluation. This technique is also more time-consuming, technically demanding, and expensive than less invasive conventional methods. The authors’ experience does provide considerable food for thought, particularly in patients in whom less invasive therapies may have otherwise failed. At present, the exact role of these less invasive treatments remains incompletely understood because high-quality trials are few and far between (19). It may be that a transarterial route for treatment for refractory cases will eventually become a standard therapy when greater experience has been accrued and a better idea of the safety and complication profiles exists.
REFERENCES 1. Okuno Y, Matsumura N, Oguro S. Transcatheter arterial embolization using imipenem/cilastatin sodium for tendinopathy and enthesopathy refractory to nonsurgical management. J Vasc Interv Radiol 2013; 24:787–792. 2. Waldenberger P, Chemelli A, Hennerbichler A, et al. Transarterial embolization for the management of hemarthrosis of the knee. Eur J Radiol 2012; 81:2737–2740. 3. Given MF, Smith P, Lyon SM, Robertson D, Thomson KR. Embolization of spontaneous hemarthrosis post total knee replacement. Cardiovasc Intervent Radiol 2008; 31:986–988. 4. Klamroth R, Gottstein S, Essers E, Landgraf H, Wilaschek M, Oldenburg J. Successful angiographic embolization of recurrent elbow and knee joint bleeds in seven patients with severe haemophilia. Haemophilia 2009; 15:247–252.
Munk
’
JVIR
5. Bagla S, Rholl KS, van BA, Sterling KM, van Breda A. Geniculate artery embolization in the management of spontaneous recurrent hemarthrosis of the knee: case series. J Vasc Interv Radiol 2013; 24: 439–442. 6. Sevilla J, Alvarez MT, Hernandez D, et al. Therapeutic embolization and surgical excision of haemophilic pseudotumour. Haemophilia 1999; 5: 360–363. 7. Kumar R, Pruthi RK, Kobrinsky N, Shaughnessy WJ, McKusick MA, Rodriguez V. Pelvic pseudotumor and pseudoaneurysm in a pediatric patient with moderate hemophilia B: successful management with arterial embolization and surgical excision. Pediatr Blood Cancer 2011; 56:484–487. 8. Pisco JM, Garcia VL, Martins JM, Mascarenhas AM. Hemophilic pseudotumor treated with transcatheter arterial embolization: case report. Angiology 1990; 41:1070–1074. 9. Lv M, Fan X, Su L, Zheng J. Ethanol embolization of hemophilic pseudotumor of the mandible. Cardiovasc Intervent Radiol 2011; 34: 880–882. 10. Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin North Am 2008; 46:515–533. 11. Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil 2013; 27:113–122. 12. Scarchilli A. Indications and limits of intra-articular oxygen-ozone therapy for rotator cuff tendinopathy. Int J Ozone Ther 2008; 7:49–52. 13. Ikonomidis ST, Iliakis EM, Eletftheriadou A, Bratanis D, Thomaidis R. Conservative treatment of acute of chronic tendonitis with oxygenozone mixture: a double blind clinical trial. Riv Ital Ossigneno-Ozonother 2003; 2:67–71. 14. MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology 2009; 252:647–661. 15. Galasso O, Amelio E, Riccelli DA, Gasparini G. Short-term outcomes of extracorporeal shock wave therapy for the treatment of chronic noncalcific tendinopathy of the supraspinatus: a double-blind, randomized, placebo-controlled trial. BMC Musculoskelet Disord 2012; 13:86. 16. Inagaki K. Current concepts of elbow-joint disorders and their treatment. J Orthop Sci 2013; 18:1–7. 17. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res 2008; 466: 1539–1554. 18. Skjong CC, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med 2012; 31:329–350. 19. Smidt N, Van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-andsee policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002; 359:657–662.
’
Number 6
’
June
’
2013
793
INVITED COMMENTARY
Musculoskeletal Intervention: Thinking Outside the Box Peter L. Munk, MDCM, FRCPC In its early years, interventional radiology was considered principally the domain of vascular radiologists. As the subspecialty evolved, biliary and gastrointestinal intervention, as well as general genitourinary intervention, formed an increasingly large part of interventional practices. During the past dozen years, musculoskeletal procedures have also come to have a higher profile, particularly with the advent of cement injection procedures and ablation technologies. Angiographic procedures dealing with the musculoskeletal system have principally been restricted to embolization procedures following trauma or in the treatment of tumors for preoperative devascularization or for treatment of vascular malformations. In a thought-provoking article, Okuno et al (1) describe their early experience with the use of transcatheter arterial embolization for treatment of recalcitrant tendinopathy and enthesopathy that had proven unresponsive to more traditional therapies. This is certainly a novel and unconventional approach to a ubiquitous problem: a rare example of vascular treatment of musculoskeletal disease outside of the aforemementioned usual three indications. Other purposes of embolization in the musculoskeletal system include the management of bleeding from synovitis (2–5). This can be seen in patients following total joint arthroplasty or in patients with hemophilia (4). Treatment of hemophiliac pseudotumors by embolization has also been described, and can be extremely helpful, particularly when pseudotumors are in surgically inaccessible sites (6–9). Tendinopathy/enthesopathy is an extremely common presenting symptom in patients, both young and old. Although certainly not life-threatening, these conditions affect quality of life and can have a major impact on the ability to work and play. Although a clear relationship does exist with overuse syndromes, the pathophysiology of these processes is extremely poorly understood and a matter of considerable debate. This lack of a clear understanding of the physiologic basis of this process is reflected in the vast From the Department of Radiology, University of British Columbia, Vancouver General Hospital and University of British Columbia Hospital, 899 West 12th Ave., Vancouver, BC, Canada V5Z 1M9. Received March 14, 2013; final revision received March 15, 2013; accepted March 15, 2013. Address correspondence to P.L.M.; E-mail: [email protected] & SIR, 2013 J Vasc Interv Radiol 2013; 24:793–794 http://dx.doi.org/10.1016/j.jvir.2013.03.016
array of different therapies used in treating this condition. These range from a variety of conservative measures involving stretching and physiotherapy, ice packs, as well as more invasive therapy involving injections of various substances. Injections have traditionally been performed with glucocorticoids, but have also been performed with other materials, such as autologous blood, platelet-enriched plasma (often admixed with activated thrombin), as well as ozone (10–14). Shockwave therapy has also been advocated, and a variety of surgical procedures, both arthroscopic and open, have been described for patients in whom the use of less invasive techniques has failed (15,16). The literature is replete with articles assessing these various therapies, and the conclusions of authors are at great variance. In short, the literature could probably accurately be described as a somewhat bewildering and confusing muddle. It seems that different patients respond to different therapies—probably at least in part a reflection of our poor understanding of the disease process and the ideal therapy (or therapies) in individual situations (17,18). Tendons and entheses are exposed to considerable stress and strain, as they are responsible for transmission of force between soft tissue and, ultimately, bone. These tissues tend to be hypocellular and generally are poorly vascularized. Yet, it has been noted that, when these structures are injured, there is often evidence of increased neovascularity, which has been extensively studied, particularly with colored Doppler ultrasound (17). Many therapies attempt to target this neovascularity and accompanying inflammation. Glucocorticoids would be an example of this, but many surgical procedures attempt to strip the highly vascularized tissues around these structures because this appears to produce relief of the patients’ symptoms. Injections of sclerosing agents are thought to potentially act by sclerosing this neovascularity. Other authorities claim that the use of agents such as hypertonic dextrose and platelet-enriched plasma can actually (at least in part) show an effect by producing irritation stimulating stem cells within the hypocellular tissues and inciting formation of fibroblasts, thereby activating repair of these damaged structures (10) Platelet-enriched plasma, in particular, is thought to act by introducing bioactive growth factors, thereby accelerating healing. At present, no one really knows for sure (11). Okuno et al (1) sought to treat the new vascularization associated with tendinopathy and enthesopathy with
794
’
Commentary: Musculoskeletal Intervention—Think Outside the Box
transarterial embolization. They deliberately selected an antibiotic particulate embolization agent (which I think is unfamiliar to most readers of this journal) with a very small particle diameter, as the new vascularity consists of tiny vessels. Their results were intriguing, as their patients’ conditions seemed to improve. Admittedly, this is something of a pilot project, as a small number of patients was treated in a wide variety of different anatomic sites. Neither I, nor, I think, the authors (1), would advocate the use of this treatment modality routinely without further evaluation. This technique is also more time-consuming, technically demanding, and expensive than less invasive conventional methods. The authors’ experience does provide considerable food for thought, particularly in patients in whom less invasive therapies may have otherwise failed. At present, the exact role of these less invasive treatments remains incompletely understood because high-quality trials are few and far between (19). It may be that a transarterial route for treatment for refractory cases will eventually become a standard therapy when greater experience has been accrued and a better idea of the safety and complication profiles exists.
REFERENCES 1. Okuno Y, Matsumura N, Oguro S. Transcatheter arterial embolization using imipenem/cilastatin sodium for tendinopathy and enthesopathy refractory to nonsurgical management. J Vasc Interv Radiol 2013; 24:787–792. 2. Waldenberger P, Chemelli A, Hennerbichler A, et al. Transarterial embolization for the management of hemarthrosis of the knee. Eur J Radiol 2012; 81:2737–2740. 3. Given MF, Smith P, Lyon SM, Robertson D, Thomson KR. Embolization of spontaneous hemarthrosis post total knee replacement. Cardiovasc Intervent Radiol 2008; 31:986–988. 4. Klamroth R, Gottstein S, Essers E, Landgraf H, Wilaschek M, Oldenburg J. Successful angiographic embolization of recurrent elbow and knee joint bleeds in seven patients with severe haemophilia. Haemophilia 2009; 15:247–252.
Munk
’
JVIR
5. Bagla S, Rholl KS, van BA, Sterling KM, van Breda A. Geniculate artery embolization in the management of spontaneous recurrent hemarthrosis of the knee: case series. J Vasc Interv Radiol 2013; 24: 439–442. 6. Sevilla J, Alvarez MT, Hernandez D, et al. Therapeutic embolization and surgical excision of haemophilic pseudotumour. Haemophilia 1999; 5: 360–363. 7. Kumar R, Pruthi RK, Kobrinsky N, Shaughnessy WJ, McKusick MA, Rodriguez V. Pelvic pseudotumor and pseudoaneurysm in a pediatric patient with moderate hemophilia B: successful management with arterial embolization and surgical excision. Pediatr Blood Cancer 2011; 56:484–487. 8. Pisco JM, Garcia VL, Martins JM, Mascarenhas AM. Hemophilic pseudotumor treated with transcatheter arterial embolization: case report. Angiology 1990; 41:1070–1074. 9. Lv M, Fan X, Su L, Zheng J. Ethanol embolization of hemophilic pseudotumor of the mandible. Cardiovasc Intervent Radiol 2011; 34: 880–882. 10. Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin North Am 2008; 46:515–533. 11. Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil 2013; 27:113–122. 12. Scarchilli A. Indications and limits of intra-articular oxygen-ozone therapy for rotator cuff tendinopathy. Int J Ozone Ther 2008; 7:49–52. 13. Ikonomidis ST, Iliakis EM, Eletftheriadou A, Bratanis D, Thomaidis R. Conservative treatment of acute of chronic tendonitis with oxygenozone mixture: a double blind clinical trial. Riv Ital Ossigneno-Ozonother 2003; 2:67–71. 14. MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology 2009; 252:647–661. 15. Galasso O, Amelio E, Riccelli DA, Gasparini G. Short-term outcomes of extracorporeal shock wave therapy for the treatment of chronic noncalcific tendinopathy of the supraspinatus: a double-blind, randomized, placebo-controlled trial. BMC Musculoskelet Disord 2012; 13:86. 16. Inagaki K. Current concepts of elbow-joint disorders and their treatment. J Orthop Sci 2013; 18:1–7. 17. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res 2008; 466: 1539–1554. 18. Skjong CC, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med 2012; 31:329–350. 19. Smidt N, Van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-andsee policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002; 359:657–662.