Guide to Musculoskeletal Injections With Ultrasound system—Ultrasonic imaging. 2. Injections, Intramuscular. I. Agha, Mohammad, editor. II. Murphy, Douglas (Douglas P.) editor. RC925.7.G84

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Guide to Musculoskeletal

Injections With Ultrasound

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New York



Editors Mohammad Agha, MD, RMSK

Assistant Professor of Physical Medicine and Rehabilitation Assistant Professor of Clinical Orthopaedic Surgery

Department of Physical Medicine and Rehabilitation Department of Orthopaedic Surgery

University of Missouri–ColumbiaColumbia, Missouri

Douglas Murphy, MD, RMSKAssociate Professor of Physical Medicine and Rehabilitation

Department of Physical Medicine and RehabilitationVirginia Commonwealth University School of Medicine

Richmond, Virginia




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Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market.

Library of Congress Cataloging-in-Publication DataGuide to musculoskeletal injections with ultrasound / editors, Mohammad Agha, Douglas Murphy. pages cm Includes bibliographical references and index. ISBN 978-1-62070-066-2—9781617052330 (e-book) 1. Musculoskeletal system—Ultrasonic imaging. 2. Injections, Intramuscular. I. Agha, Mohammad, editor. II. Murphy, Douglas (Douglas P.) editor. RC925.7.G84 2015 616.7’07548—dc23 2015015029

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To my mother, Shamim Agha, who sets the example of the person I want to be—MTA

To Paul D. Murphy, MD and Andrea Murphy—DM







Contents

Contributors xiForeword David X. Cifu, MD xvPreface xviiAcknowledgments xix

Chapter 1. Essentials of Musculoskeletal Ultrasound 1Mohammad Agha

Chapter 2. Shoulder Injections 15Michael P. Schaefer and Victor Foorsov

Subacromial/Subdeltoid Bursa 16Biceps Tendon Sheath (Biceps—Long Head) 19Acromioclavicular Joint 23Glenohumeral Joint 26

Chapter 3. Elbow Injections 33Christopher Wolf, Brian Toedebusch, and Peter Dawson

Common Extensor Tendon 34Common Flexor Tendon 36Olecranon Bursa Injection 38Ulnar Nerve Injection (Below Cubital Tunnel) 40Pronator Teres Syndrome (Median Nerve) 42Intra-Articular Elbow Injection 44

Chapter 4. Wrist and Hand Injections 47P. Troy Henning

Carpal Tunnel Injection 48Cubital Tunnel Injection 51De Quervain’s Tenosynovitis 54Extensor Carpi Ulnaris Tenosynovitis 58Intersection Syndrome 62Carpometacarpal Joint Injection 65Trigger Finger/Thumb 69




Chapter 5. Hip Injections 75Rosalyn Nguyen and Eugene Roh

Hip Intra-Articular Joint Injection 76Ischial Bursa Injection 78Lateral Femoral Cutaneous Nerve Injection 80Trochanteric Bursa Injection 82Gluteus Medius/Minimus Bursa Injection 87Iliopsoas Bursa Injection 90

Chapter 6. Knee Injections 95Douglas Murphy and Javier I. Soares

Access Through the Suprapatellar Bursa or Recess 96Knee Joint Injections: Anterior Approach 99Pes Anserine Bursa Injection 101Deep Infrapatellar Bursa Injection 103Iliotibial Band Syndrome 105

Chapter 7. Ankle/Foot Injections 109Douglas Murphy, Mohammad Agha, and Javier I. Soares

Ankle Joint Injection 109Peroneal Tendonitis 112Posterior Ankle Impingement 115Plantar Fasciitis Injection 118Morton’s Neuroma 121Retrocalcaneal Bursitis 124

Chapter 8. Cervical Spine and Intercostal Injections 129Anuj Bhatia

Medial Branch Block 130Intra-Articular Facet Joint Injection 135Selective Nerve Root Block 139Intercostal Nerve Block 144

viii • CONTENTS




Chapter 9. Caudal Epidural Injection and Piriformis Muscle Injection 151Carl P. C. Chen and Henry L. Lew

Ultrasound-Guided Caudal Epidural Injection Technique 151

Ultrasound-Guided Piriformis Injection 154

Index 159

CONTENTS • ix







Contributors

Mohammad Agha, MD, RMSKAssistant Professor of Physical Medicine and Rehabilitation Assistant Professor of Clinical Orthopaedic Surgery Department of Physical Medicine and Rehabilitation Department of Orthopaedic Surgery University of Missouri–ColumbiaColumbia, Missouri

Anuj Bhatia, MBBS, DNB, MD, FRCA, MNAMS, FFPMRCA, FIPP, FRCPC, EDRA, CIPSAssistant ProfessorDepartment of Anesthesia and Pain ManagementUniversity of Toronto;Department of Anesthesia and Pain ManagementToronto Western HospitalToronto, Ontario, Canada

Carl P. C. Chen, MD, PhDAssociate Professor/DirectorDepartment of Physical Medicine and RehabilitationChang Gung Memorial HospitalTaipei, Taiwan

Peter Dawson, MDResident PhysicianDepartment of Physical Medicine and RehabilitationUniversity of Missouri–ColumbiaColumbia, Missouri




xii • CONTRIBUTORS

Victor Foorsov, MDResidentDepartment of Physical Medicine and RehabilitationCase Western Reserve University/MetroHealth Medical CenterCleveland, Ohio

P. Troy Henning, DOAssistant ProfessorDepartment of Physical Medicine and RehabilitationUniversity of MichiganAnn Arbor, Michigan

Henry L. Lew, MD, PhDProfessorJohn A. Burns School of Medicine University of Hawaii at Ma-noa Honolulu, Hawaii;ProfessorDepartment of Physical Medicine and RehabilitationVirginia Commonwealth University School of MedicineRichmond, Virginia

Douglas Murphy, MD, RMSKAssociate Professor Department of Physical Medicine and RehabilitationVirginia Commonwealth University School of MedicineRichmond, Virginia

Rosalyn Nguyen, MDAssistant ProfessorSports Medicine, Physical Medicine and RehabilitationBaylor College of MedicineHouston, Texas




CONTRIBUTORS • xiii

Eugene Roh, MDClinical Assistant ProfessorPhysical Medicine and Rehabilitation Department of OrthopaedicsStanford UniversityRedwood City, California

Michael P. Schaefer, MD, RMSKDirector of Musculoskeletal Physical Medicine and RehabilitationDepartment of Physical Medicine and Rehabilitation and Orthopaedic and

Rheumatologic InstituteCleveland Clinic FoundationCleveland, Ohio

Javier I. Soares, MDPolytrauma and Amputee/MSK Rehab Fellow Physician Department of Physical Medicine and Rehabilitation Hunter Holmes McGuire VA Medical Center Richmond, Virginia

Brian Toedebusch, MDResident PhysicianDepartment of Physical Medicine and RehabilitationUniversity of Missouri–ColumbiaColumbia, Missouri

Christopher Wolf, DO, FAAPMRAssistant ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Missouri–ColumbiaColumbia, Missouri







Foreword

The Guide to Musculoskeletal Injections With Ultrasound is a must for clinicians. For too long and in too many studies, we have known that per-forming injections without guidance results in misplaced and poorly placed treatments and less than optimal results. Given the virtual explosion in the number and types of clinicians using therapeutic injections as an adjunct in the management of musculoskeletal medicine, this cutting-edge manual will quickly fill a vital niche in the clinic. While it can also serve as an excellent teaching tool for academics, it is first and foremost a hands-on tool for the practitioner. Finally, an easy-to-use, illustrated guide is here that allows clinicians to take advantage of ultrasound (US) technology to accurately and efficiently deliver injectate to where it can be most effec-tive. Drs. Agha and Murphy offer a practical approach to using diagnos-tic US to guide therapeutic injections. From the clear and succinct text to the illustrative photographs, this guide offers readers both a better under-standing of US technology and the functional anatomy it reveals. Years of experience and thousands of accurate injections went into the creation of this text, and readers will be able to quickly leverage all this expertise into their day-to-day practice. This guide will serve to accurately answer a key therapeutic question: Am I in the right spot? Given the challenges and complexities of musculoskeletal medicine, clarifying yet another element of the therapeutic approach is invaluable. I would advocate keeping a copy of Guide to Musculoskeletal Injections With Ultrasound in every clinic room in your offices.

David X. Cifu, MDChairman and Herman J. Flax, MD Professor

Department of Physical Medicine and RehabilitationFounding Director, Center for Rehabilitation Sciences and Engineering

Virginia Commonwealth University;National Director for Physical Medicine and Rehabilitation Services

Department of Veterans AffairsRichmond, Virginia







Preface

As an attending physician at an academic medical center, I frequently have residents and fellows rotating through my clinics to gain exposure to musculoskeletal ultrasound (US). Most of them want to learn how to do the “textbook” injections under US guidance. Specifically, they were looking for a book that could both help the beginner transition to an intermediate level and also provide the information in a digestible format they could readily use in clinic. With this book, bridging the experience gap is now much easier.

Thus, the goals of this handbook are simple: first, to help those who are new to the world of musculoskeletal US to safely and effectively learn common injections; second, to organize the information such that the reader can quickly access a small detail or read through the full range of specifics contained in an entire section. The content is focused on giving the beginner the knowledge and skills needed to know how to perform an injection in clinic. This handbook makes a process that requires a lot of practice easier, by building confidence, and launching clinicians on the road to proficiency.

This book is not meant to be the end-all of US books or the only tool needed in training; instead, view it as the bridge between your entry into the world of musculoskeletal US and the next level of proficiency. The final step to true expertise will then follow with repetition, practice, and mentorship. Most of the injections outlined in this handbook are com-monly performed in musculoskeletal and sports medicine clinics across the United States. The more specialized injections presented at the end of the book on cervical spine and pelvis injections highlight the exciting potential of more advanced interventional musculoskeletal US. All these techniques should be practiced and used with the appropriate level of supervision and mentorship, and I recommend that these more advanced skills be initially done in the setting of fellowship training to ensure that they are taught by experienced practitioners.




xviii • PREFACE

The authors and editors are enthusiastic about the use of this handbook to enhance the care of your patients. Dr. Murphy and I look forward to any questions and comments that you may have.

Mohammad Agha, MD, RMSK




Acknowledgments

Anytime a group undertakes a large project such as this one, its success depends on the people involved. My thanks go out to the following peo-ple who helped make this book a reality: to my parents, Shamim and Dr. Sirajuddin Agha, who helped make me the person that I am today; to my uncles Dr. Amanullah Pathan and Dr. Karamullah Pathan, for being great role models; to my sisters Lubna, Rafiya, and Iram, and to my wife Aisha, for their support; and to the physicians who helped me get to where I am today: Dr. David Cifu, Dr. William McKinley, Dr. Doug Murphy, Dr. Abu Qutubuddin, and Dr. Robert Rinaldi. I also have to thank Dr. Greg Worsowicz and Dr. James Stannard for their decision to hire me onto the faculty at the University of Missouri. Thank you also to Dr. Ted Choma and Dr. Mark Drymalski for their mentorship. Thank you to Demos Medical Publishing and Beth Barry, who supported this project and helped get it off the ground. And finally, my thanks go out to the authors of each chapter, for helping to make this book a resource for ultrasound practitioners so they can practice medicine at a higher level.















CHAPTER 1

Essentials of

Musculoskeletal Ultrasound

Mohammad Agha

CHARACTERISTICS OF ULTRASOUND

• Anultrasound(US)wave isgeneratedbyaUSmachine thatconvertselectricalenergytoasoundwaveatthetransducer/gelinterface(piezo-electriceffect).

• The wave is then propagated through tissue and returns back to thetransducer.

• Whenreturningtothetransducer,thewaveisconvertedbacktoelectri-calenergy,producingaUSimage(reversepiezoelectriceffect).

• MultipleoutcomesoccurwhenaUSwaveleavesthetransducer:

1. Refraction:wavedirectionchangesasitpassesthroughfluid.2. Reflection:wavehitsstructure,returningtotransducer.3. Scatter:Refraction+Reflectionawayfromtransducer(1,2).4. Artifacts(seethefollowing).

• Remember thatmostof theenergy from the transducer is lost asdis-sipatedheat.

US TRANSDUCERS

• Linear:goodforsuperficialstructures(Figure1.1).• Curvilinear:goodforcurved/deepstructures(Figure1.2).• Smallfootprint(“hockeystick”):goodforareasoflimitedcontact(wrist,

ankle)(Figure1.3).• Eachprobe’suseisdependentonthedepthofstructureofinterest.




2 • 1:ESSEnTiALSoFMUSCULoSkELETALULTRASoUnd

• Linearprobeshavehighfrequency(typically>10MHz),whichprovideshighresolution,butlowpenetration/depth(upto6cm).

• Curvilinear probes have lower frequencies, which provide lowerresolution, but increased penetration/depth (for structures such asthehip)(2).

Figure 1.1 Linear probe: L4-12t-RS LoGIQ e wide band linear array probe with 4.2–13 MHz frequency. Courtesy of GE.

Figure 1.2 Curvilinear probe: C1-5-RS LOGIQ e wide band convex array probe with 2–5 MHz frequency. Courtesy of GE.




ARTiFACTS • 3

SCANNING TECHNIQUE

• PositiontheUSmachinenearpatientformaximalviewingarea.• Holdtheprobebetweenyourthumbandfingerofyourdominanthand.• Besuretowrapyourentirehandaroundtheprobe,withtheendofthe

probenearthefifthdigit.• Maintainscanninghandcontactwithpatientatalltimeswhilescanning—

itincreasesstabilitywhenscanningandinjectingapatient.• keepyourscanninghandlowerthanyourshoulder.• keepyourelbowclosetoyourbody.• Canperformtwotechniqueswithprobetoimproveimageresolution.

• Heel-toe:movingtheprobelong-axis.• Toggling:movingprobeshort-axis(2).

ARTIFACTS

• Anisotropy: when the sound wave is not perpendicular to object ofinterest,theimagingtraitofthetissue(whenoffaslittleas5°)islost.Thistypicallyresultsindarkeningoftissue,mimickingpathology.

Figure 1.3 Hockey stick probe: L8-18i-RS LOGIQ e wide band high-frequency linear array probe with 6.7–18 MHz frequency. Courtesy of GE.





• Shadowing: US beam is refracted, reflected, or absorbed, causing ananechoic(black)imagedeeptotheobject(typicallybeneathbone,withgas,ordeeptoacalcification).

• Posterior acoustic shadowing: soft tissuedeep to anobject is hypere-choic(brighter)comparedtoadjacentsofttissue.Typicallyoccurswithpresenceoffluidorsolidsofttissuetumor.

• Posterior reverberation: a smooth/flat object reflects the sound beambackandforthbetweenitselfandthetransducer,causinglinearechoesdeep to the structure. if it continuesdeeper, called ring-down artifact(associatedwithmetal).

• Comettail:deephyperechoicechoesduetosofttissuegas.• Beamwidthartifact:beamtoowiderelativetoimagedobject.Corrected

byaddingfocalzone(seethefollowing)tolevelofobject(1).

DOPPLER

• dopplereffect:colorflowchangesasobjectmovestowardorawayfromanobject.

• Colorflow:coloredbloodflowindicatingdirectionofbloodflow(red:towardtransducer;blue:away).

• duplexdoppler:US+waveformrecorded.• Powerdoppler:sensitive tobloodflowandtransducermovement,but

doesnotprovidedirectionalinformation.• increasedflowonpowerdopplercanindicateinflammation,increased

perfusion,orneovascularization.• Powerdopplercanalsohelpwithidentifyingotherstructures.• Masswithflowgenerallyindicatesmalignancy,comparedtomasswithout

flow,whichgenerallyindicatesbenign;mass(alwaysbiopsytobesure).• Lymphnode:noflow/hilarflow:generallybenign; spotted/peripheral/

mixedflow:generallymalignant(again,biopsytobesure).• Complexfluidversussynovitis.• Complexfluid:nointernalflowonpowerdoppler.• Synovitis:increasedflow(1).

US PROBE CHARACTERISTICS

Linear: high frequency (>10 MHz), better resolution, less depth(Table1.1).




iMAGEoPTiMiZATion • 5

Curvilinear:lowerfrequency(2–5MHz),decreasedresolution,increaseddepth(Table1.2).Hockey stick: high frequency (>10 MHz), increased resolution, lessdepth,bestforsmallerstructures.

IMAGE OPTIMIZATION

1. Selecttheproper transducer.2. Adjustfocal zonestoimprovebrightnessattheleveloftheobjectofinterest

(onlyaddminimumnumberneeded;otherwiseitreducesframerate).3. Adjustgainforappropriateoverallbrightnessonscreentoidentifylocal

structures.4. Adjustdepth gain/time gain compensationtoaddbrightnessatspecific

areaofscreen(3).

Theimageproducedhasobjectswithdifferenceintensities:• Hyperechoic: object brighter than surrounding objects (ligament, ten-

don,bone,calcification).• Hypoechoic:objectdarkerthansurroundingstructures(fluid,tendinosis,

tear).• isoechoic: object has equal brightness in relation to surrounding

structures.• Anechoic:object/areadark(black)(2)(bloodvessel,fluid,cartilage).

Table 1.1 Advantages of Ultrasound

High-resolution images

Real-time imaging

Dynamic examination

Procedure guidance

Can compare contralaterally

No radiation

Portable

No known contraindications

Relatively inexpensive





individual musculoskeletal structures each have defined intensitycharacteristics.noteagainthatthesetermsdescribeobjectintensityrela-tionships relative to surrounding structures. Therefore, objects that arehyperechoicinoneimagecanbehypoechoic(relativetoanotherstructure)inanotherimage.

APPEARANCE OF NORMAL STRUCTURES UNDER ULTRASOUND (4)

Tendon:hyperechoic,linear,fibrillarLigament:hyperechoic,linear,fibrillar,morecompactthantendonMuscle:relativelyhypoechoic,withhyperechoicfascialplanesBone:hyperechoicinterface,anechoicdeeptoboneHyalinecartilage:hypoechoic,uniformFibrocartilage:hyperechoicPeripheral nerve: fascicular appearance, with hypoechoic nerve fasci-cles,andhyperemicconnectivetissueepineurium(3)

INJECTATES

Corticosteroids

• naturalsubstanceformedintheadrenalcortex.• Mechanism of action: down-regulate immune function; inhibit cell-

mediatedimmunity;altermRnAproduction,alteringproteinannexin-i.• Have mineralcorticoid (water/electrolyte) and glucocorticoid-

(metabolism/inflammatory)properties.• Steroidscanbesolubleorinsoluble,meaningsomehaveesters(water

insoluble),causingthemtoformmicrocrystals.

Table 1.2 Disadvantages of Ultrasound (Technical, Examiner, Equipment)

Limited field of view

Operator dependent

Limited penetration




AdVERSEEFFECTS • 7

• BetamethasoneanddexamethasonedonoThaveesters, thustheyarebrokendownviahydrolysisbythebody’scellesterases.

• Thisleadstolongereffectinjoint.• Estershavequickeronset,butdecreasedduration(Table1.3,Table1.4).

ADVERSE EFFECTS

• Septicarthritis• Postinjection flare (most common adverse effect, develops in a few

hours,lasts2–3days)

Table 1.3 Commonly Injected Corticosteroids

Steroid Equivalent Potency % Particles >10 µm

Methylprednisolone acetate 4 45

Triamcinolone acetonide 4 45

Betamethasone acetate/sodium phosphate

0.75 35

Dexamethasone sodium phosphate

0.75 0

Table 1.4 Different Steroid Doses for Variably Sized Joints (5)

Joint Size

Methylprednisolone Acetate (mg)

Triamcinolone Acetate (mg)

Betamethasones (mg)

Dexamethasone Sodium Phosphate (mg)

Large 20–80 10–15 1–2 2–4

Medium 10–40 5–10 0.5–1.0 2–3

Small 4–10 2.5–5 0.25–0.5 0.8–1

Large: shoulder, hip, knee, ankle. Medium: elbow, wrist. Small: MCP, AC joint.





• Localtissueatrophy• Tendonrupture• Cartilagedamage• Facialflushing• Chills/shakes/headache(histaminereleasefromsteroid)• increasedbloodglucoselevels• Localtissuenecrosis• Calcification• Skinatrophy/depigmentation

ADVERSE CENTRAL NERVOUS SYSTEM EFFECTS

• Tetraplegia/paraplegia• Can be due to brain/spinal cord infarction, vascular injury, embolism

from steroid particulate (most likely), neurotoxicity from preservative(benzylalcohol),ordrugvehicle(polyethyleneglycol)

CONTRAINDICATIONS FOR CORTICOSTEROID INJECTIONS

• Absolute:Sepsis (systemic/intra-articular), intra-articular fracture, andjointinstability.

• Relative: Juxta-articular osteoporosis, coagulopathy, joint injectionmorethanthreetimesperyear,oroneinjectioninthelast6weeks.

LOCAL ANESTHETICS (TABLE 1.5)

• inhibitnerveexcitationthroughsodiumchannelblockadeatcellmem-brane(inhibitsactionpotential).

• Effective analgesic due to blocking smaller diameter nerves (ie, painfibers).

• Twocategories:amides(lidocaine)andesters.• Canbeadministeredwithvasoconstrictortodecreasevascularabsorp-

tion,increasingduration.• Anesthetic characteristics determined by acid dissociation pK

a, lipid

solubility,proteinbinding.




LoCALAnESTHETiCS • 9

• pKa:onsetofaction.

• Lipidsolubility:nervemembranepenetration(highersolubility:higherpenetration).

• Proteinbinding:durationofaction.

Contraindications

• Sensitivitytoamideanesthetic• Localinfection• Coagulopathy• Epinephrine use if patient uses monoamine oxidase (MAo) inhibitor/

tricyclicantidepressants(TCA)(prolongedhypertension).

Adverse Side Effects

• Centralnervoussystem:shivering,muscletwitches,tremor,hypoventi-lation,andconvulsions.

• Cardiac:arrhythmias,cardiovascular(CV)depression/collapse.• Anaphylaxis:lossofconsciousness,convulsions,andCVeffects.• Skeletalmuscletoxicity:necrosis,cellapoptosisduetopermanentintra-

cellularcalcium,muscleweakness,andchondrocytetoxicity.

Table 1.5 Commonly Used Local Anesthetics

Generic Name (min)

Relative Potency

Onset Duration of Action (min)

Procaine hydrochloride

1 Moderate 30–60

Lidocaine hydrochloride

2 Rapid 80–120

Ropivacaine hydrochloride

6 Moderate 140–200

Bupivacaine hydrochloride

8 Long (2–10 min) 180–360





PLATELETRICH PLASMA (6)

• Plateletshavealphagranulesthatreleasegrowthfactors.• Thesegrowthfactorsaresmallpeptidesthatbindmembranereceptors

andpromotedownstreampathways.• Also mediate chemotaxis and cell migration through “chemical

mediators.”• Canalsoaffectmitosis,angiogenesis,andcelldifferentiation.• Platelet-richplasma(PRP)preppedfromautologouswholeblood.• Spundownbycentrifugetoproducethreelayers:

1. plasmalayer(top)2. plateletsandwhitebloodcells(WBC)3. redbloodcells

• Middlelayer(PRP)suctionedout;canaddcalciumchlorideorthrombintoactivateplatelets.

• Thisreleases70%growthfactorsin10minutes.• it’sbelievedthatneedlingthestructureofinterestcausesfocalbleeding

andacuteinflammatoryresponse,aidingcellrecruitmentandrepair.

VARIOUS BLOOD PRODUCTS

• Autologousconditionedserum:wholeblooddrawnintoglassbeadstostartmonocyteactivation.

• Autologousplasma rich ingrowth factors (PRGF):venousbloodcol-lectedin5mLtubeswith3.8%trisodiumcitrate,centrifugedat1,800rpmfor8minutes.0.25to1mLfractiontransferredtosteriletubes.Calciumadded,formingfibrinmatrixwithplatelets.

• Autologousconditionedplasma:wholebloodcentrifugedtoformPRP,thenplaced intobottlewithcalciumchloride incentrifuge toproduceplateletfibrinmatrix.

• Plateletleukocyte-richgel:centrifugewholebloodtoproducePRPandleukocyte-richplasma(toplayer),whicharemixedtogetherwiththrom-binorcalciumchloridetoformagel.it is thoughtthataddingWBCsconfersantibacterialproperties.

• Autologousbloodinjections:wholevenousbloodmixedwithlidocaineorbupivacaineforinjection.




STEMCELLS • 11

STEM CELLS (7)

• Threebasiccategories:embryonic,adult (mesenchymal), and inducedpluripotent.

• Moststudied:mesenchymalstemcells.• isolatedfrommanytissues(bonemarrow,muscleadipose).• Thecloseratissueistocelllineofdesiredtissue,themoreeffectiveat

differentiatingintodesiredcellline.• Cellscanbeusedfromculturedlinesorsame-daysample.

To Culture Stem Cells

• Seedcellsontomonolayerflask• Attachtosurface• Adherentcellsgetculturemediumtogrow• Growthcontinuesuntilcellstoucheachother• oncetheytouchtheystopgrowing(confluence)• Cellsarethenplacedintoanotherflaskandmedium(passage)

SameDay Use

• Harvesttissuefromadipose• Releasecellsorgetfractionbybreakingdowncollagenmatrixtocentri-

fugecells

Mechanisms of Action

• Celldifferentiation• Paracrine effects (chemokine secretion, suppressed dendritic cells,

reducedeffectorTcells/nkcells/MHCClassiicells)• Macrophagedeactivation(preventsfurthermetabolism)

Autologous vs. Allogeneic Cell Lines

• Autologous: carry more genetic variants; decreased differentiation ifolderpatients.

• Allogeneic:massproductionpossible;canactivatehostimmunesystem(iL-6deregulation).





• AdministrationofstemcellsregulatedbyFoodanddrugAdministration(FdA)(FdATissueRegulation,21CFRPart1271)(8).

• FdAdoesnotallowextendedexvivoculturingofgrowthfactors,andonlyallows“minimallymanipulatedtissue”(8).




REFEREnCES • 13

REFERENCES

1. Jacobson JA. introduction. Fundamentals of Musculoskeletal Ultrasound.Philadelphia,PA:ElsevierSaunders;2007:1–14.

2. kirschnerJS.introduction.in:SpinnerdA,kirchsnerJS,HerreraJE.Atlas of Ultrasound Guided Musculoskeletal Injections. new York,nY:Springer;2014:1–4.

3. Smith J, Finnoff JT. diagnostic and interventional musculoskeletalultrasound.Part1:fundamentals.PM&R.2009;1(1):64–75.

4. Smith J, Finnoff JT. diagnostic and interventional musculoskeletalultrasound.Part2:clinicalapplications.PM&R.2009;1(2):162–177.

5. MacMahon PJ, Eustace SJ, kavanagh EC. injectable steroids andlocal anesthetic preparations: a review for radiologists. Radiology.2009;252(3):647–661.

6. nguyen RT, Borg-Stein J, Mcinnis k. Applications of platelet-richplasma in musculoskeletal and sports medicine: an evidence-basedapproach.PM&R.2011;3:226–250.

7. Centeno CJ. Clinical challenges and opportunities of mesenchymalstemcellsinmusculoskeletalmedicine.PM&R.2014;6:70–77.

8. BashirJ,ShermanA,LeeH,etal.Mesenchymalstemcelltherapiesinthetreatmentofmusculoskeletaldiseases.PM&R.2014;6:61–69.


Documents

Guide to Musculoskeletal Injections With Ultrasound system—Ultrasonic imaging. 2. Injections, Intramuscular. I. Agha, Mohammad, editor. II. Murphy, Douglas (Douglas P.) editor. RC925.7.G84