Editorial Comment on: B. Kowalska Ultrasound-guided joint and soft tissue interventions.

Berta Kowalska in her paper( has given a clear and concise overview of the ultrasound technique for performing ultrasound-guided interventions, mainly outlining the use of steroid injections and aspiration. Standardization and clear guidelines on these techniques will improve their efficacy and development. It was beyond the remit of the article to cover some of the finer details of peri-procedural technique or to evaluate some of the more controversial issues regarding ultrasound-guided injections. I would however encourage readers to consider some of these issues, which are addressed under the various headings below.

Consent

The importance of informed consent is essential, particularly in the increasingly litigious societies in which we live. Ideally written consent should be obtained, but if this is not deemed appropriate, a written record of the verbal consent detailing the risks should at least be kept(. Sending out an information leaflet, at the same time that the procedure is booked, is an excellent way of ensuring that the patient is kept well informed.

Post-procedural care

The benefits may be enhanced, and risks reduced of many ultrasound-guided procedures by post-procedural behavior modification. This would include rest or immobilization (such as the use of an Aircast boot following tendon injections to minimize the risk of tendon rupture) and appropriate physiotherapy (such as eccentric exercises), along with the use of podiatry and orthotics.

Feedback

The use of a pain diary to document the improvement or lack of benefit from an interventional procedure can be extremely useful. The outcome of the injection can be documented, and the result fed back to referring clinician. Furthermore, the feedback enables the person performing the procedure to assess if the intervention has worked or not, and to audit their results.

Rationale for steroid injection

The rationale for steroid injection in the treatment of tendinosis has been widely questioned. Tendinopathy is now understood to be a degenerative rather than an inflammatory process. With this realization, there is increased emphasis on sing alternatives to steroid for tendon therapy. Steroid has been shown to increase the risk of tendon rupture, particularly when used around the weight bearing tendons of the ankle, particularly the Achilles(. Increa singly it is recogn ized t hat steroid inject ions, although efficacious for pain relief in the short term, may not provide lasting benefits(. The frequency with which steroid injections can be repeated safely is also an issue that requires addressing.

Novel interventional techniques

The article does not address many of the novel interventional techniques that are now commonly performed under ultrasound guidance. These would include barbotage, dryneedling, high volume guided injections (HVGI), needle tenotomy, prolotherapy, cryotherapy and radio-frequency ablation(. The use of alternative injectates, including alcohol, Botulinum Toxin A, aprotonin, tenocyte–like cells, autologous blood, platelet rich plasma and stem cells now constitute a significant proportion of interventional procedures undertaken, and slowly some evidence is emerging that these may be more effective than some traditional therapies(. Nevertheless, there remains a very large chasm between what has now become adopted practice, and the rather scant evidence base for this(. Therefore, it is incumbent upon the medical profession to produce well-designed randomized controlled studies to evaluate the efficacy of these new techniques. Many questions regarding the optimal timing, dosage, injection technique and injection volume remain unanswered.

Inappropriate interventions

There are specific situations when interventional therapies although technically feasible, should not be undertaken.

The World Anti-Doping Authority (WADA) publishes a prohibited list annually that includes prohibited methods and substances in elite athletes. Section S2 states that it is prohibited to administer growth factors, including platelet-derived preparations by an intramuscular route.

Biopsy of soft tissue tumours outside of designated tumour centres in many countries is discouraged, as an incorrect route of biopsy may lead to tumour seeding or interfere with the ideal surgical approach(.

Are guided injections actually more effective?

Numerous studies have shown that the use of ultrasound is superior to blind injections using anatomical landmarks for guiding the needle. It should therefore follow that guided injections are always superior to blind injections, but that is not necessarily the case. A recent Cochrane review of blind versus guided injections showed no difference in outcomes for subacromial injections(.