Technique Accuracy and Outcome Studies

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Appendix 1 Landmark Technique Accuracy and Outcome Studies

For references please see the list for Section 1, Landmark and image guided injections, page 54–59. The tables summarize:

1. Cadaver studies of accurate placement

2. Clinical studies of accurate placement on live patients

3. Clinical studies of outcomes comparing landmark with image guided techniques

4. Clinical studies of accurate placement and outcomes between landmark and image guided techniques.

Cadaver studies were landmark guided and used dye injection and dissection to determine accuracy of placement unless otherwise stated.

Glenohumeral joint

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Clinical outcomes where relevant Comments (imaging assessment)
Sethi ¹⁸ 2006 Cadaver Accuracy	Anterior approach 80% (16/20) Posterior approach 50% (10/20)	(X-ray with contrast)
Hanchard²² 2006 Cadaver Accuracy	74–91% (worst and best results for different approaches)	Best results with ‘optimized’ technique; 16% dispersal into other structures
Esenyel⁸¹ 2010 Cadaver Accuracy	Anterior 96% (48/50)	4% were in surrounding tissues and capsule
Sethi¹⁹ 2005 Clinical Accuracy	Anterior 27% (11/41)	Insertion just lateral to the coracoid. Most common misplacement either too medial or too superficial in the deltoid muscle (MRI arthrography)
Lee⁵⁷ 2009 Clinical Outcome	Posterior landmark guided (22) vs Ultrasound guided (21) (43 patients with frozen shoulder)	2 weeks post-injection improvement was significantly greater in the US-guided injection group, but there was no significant difference in the improvement between the 2 groups beyond the 3rd week up to 6 weeks
Hegedus² 2010 Clinical Accuracy and Outcome	Multiple approaches 52% (54/103)	4 weeks post-injection equal improvement in all regardless of accuracy, despite wide variance in subject duration of symptoms, multiple injectors with varied training, and multiple injection approaches. Accuracy did not appear to depend on the experience of the physician (X-ray fluoroscopy)
Eustace¹⁷ 1997 Clinical Accuracy and Outcome	42% (10/24)	There were significant differences in outcome between the accurately placed and the inaccurately placed groups (X-ray with contrast)

Subacromial space

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Clinical outcomes where relevant Comments (imaging assessment)
Partington²¹ 1998 Cadaver Accuracy	83% (20/24)	Other structures also infiltrated in 15 shoulders incl. 7 into the cuff
Hanchard²² 2006 Cadaver Accuracy	91%	Best results with ‘optimized’ technique; 19% dispersal into other structures
Rutten²⁶ 2007 Clinical Accuracy	Ultrasound guided 100% (10/10) vs Landmark guided 100% (10/10)	(MRI arthrography)
Yamakado³³ 2002 Clinical Accuracy	70% (39/56)	12 (21%) were in the deltoid muscle, 2 (4%) were in the glenohumeral joint, 3 (5%) were subcutaneous. Comparison of subacromial bursal with intradeltoid injection showed no immediate significant differences in pain reduction expressed as impingement signs (X-ray with contrast)
Kang³⁴ 2008 Clinical Accuracy and Outcome	Anterolateral 70% (14/20) Lateral 70% (14/20) Posterior 70% (14/20)	At 3 months there was significant clinical improvement that did not correlate with accuracy. Accuracy not related to body mass index (X-ray with contrast)
Naredo⁵⁸ 2004 Clinical Accuracy and Outcome	Landmark guided (20) vs. Ultrasound guided (21)	6 weeks post-injection, there was significantly greater improvement with US versus LG. Suggest that US guided injections should be indicated, at least, in patients with poor response to previous blind injection to ensure accurate medication placement (ultrasound)
Esenyel²⁷ 2003 Clinical Accuracy and Outcome	Anterolateral 87% (42/48)	2 weeks after treatment, failure of accurate placement was associated with return to pre-treatment values, while significant improvement continued in the other group (X-ray with contrast)
Eustace¹⁷ 1997 Clinical Accuracy and Outcome	29% (4/14)	There were significant differences in outcome between the accurately placed and the inaccurately placed groups (X-ray with contrast)

Acromioclavicular joint

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Comments (imaging assessment)
Partington²¹ 1998 Cadaver Accuracy	67% (16/24)	Other structures also infiltrated in 8 shoulders
Pichler³ 2009 Cadaver Accuracy	57% (33/76)	Skilled specialist and inexperienced resident equally accurate. (Specialist 20/20 accurate with use of an image intensifier)
Bisbinas³⁵ 2006 Clinical Accuracy	40% (26/66)	Injections were misplaced laterally in 21 injections (31.8%), medially in 13 (19.8%), anteriorly in 3 (4.5%) and inferiorly in 3 (4.5%) (image intensifier)

Suprascapular nerve

Lead author Year Subject Study type	Study protocol	Clinical outcomes Comments
Shanahan⁵⁹ 2004 Clinical Outcome	Landmark guided vs CT guided (77 shoulders in 67 patients)	12 weeks post-injection, significant improvements in pain scores and disability with both types of nerve block, no difference in the improvement between the two at any time. No significant adverse effects occurred in either group. Patient satisfaction scores for pain relief high for both

De quervain’s

Lead author Year Subject Study type	Accuracy % (proportion of tendon sheaths injected)	Clinical outcomes where relevant Comments (imaging assessment)
Zingas³⁰ 1998 Clinical Accuracy	Accuracy of first dorsal compartment injection 84% (16/19)	Symptom relief in 58% (11/19) (X-ray with contrast in tendon sheath)

Carpal tunnel syndrome

Lead author Year Subject Study type	Safety (proportion of times needle pierced median nerve [MN])	Comments
MacLennan⁸² 2009 Cadaver Accuracy	1. Entry point just ulnar to palmaris longus (4/15) vs 2. Entry point just ulnar to palpable ulnar border of flexor carpi radialis (1/15) Both injections given at 30°angle at the wrist crease

Method 1. Needle mean distance from MN 1.34 mm ± 1.83 mm
Method 2. Needle mean distance from MN 4.79 mm ±3.96 mm
Method 1. Needle mean distance from palmar cutaneous branch 9.47 mm ± 4.11 mm
Method 2. Needle mean distance from palmar cutaneous branch 1.74 mm ±1.59 mm Ozturk⁸³ 2008
Cadaver Accuracy

1. Entry point just ulnar to palmaris longus vs

2. Entry point through the flexor carpi radialis tendon vs

3. Entry point just distal to the distal skin crease of the wrist in line with the fourth ray

1 and 2 given at 45° angle 1 cm proximal to the wrist crease Method 1. MN injuries caused by injection was seen mostly with this technique
Method 2. Highest accuracy rate, and safest injection site*

* Injection through FCR tendon also recommended by Dubert & Racasan 2006⁸⁴ based on endoscopic survey of the anatomy of the carpal tunnel during 124 release operations

Trapeziometacarpal joint

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Comments (imaging assessment)
Helm³⁶ 2003 Clinical Accuracy	58% (35/60)	(X-ray fluoroscopy)
Pollard²⁹ 2007 Clinical Accuracy	82% (18/22)	Soft-tissue extravasation in 25% (X-ray fluoroscopy)

Fingers

Lead author Year Subject Study type	Accuracy % (proportion of joints/tendon sheaths injected)	Comments
Pichler²⁰ 2008 Cadaver Accuracy	Skilled specialist 85% Inexperienced resident 77% (300 DIPs/PIPs) Dorsal approach (150) Dorsolateral approach (150)	The failure rate was significantly higher than the average with the joints of the little finger and the DIP joints of each phalanx
Kamhin¹⁰ 1983 Clinical Accuracy	Patients scheduled for surgical release of trigger fingers had an injection of the involved tendon sheath prior to surgery. 61% (22/36) methylene blue injected proximal-distal direction 37% (13/34) methylene blue injected distal-proximal direction	There was no significant statistical difference with regard to age, but duration of the disorder and mode of injection regarding the different fingers did have statistical significance
Taras⁶⁶ 1998 Clinical Accuracy and Outcome	95 patients with 107 trigger digits, 52 attempted intra-sheath injections; of these: 1. 37% digits (19) injected within the sheath 2. 46% (24) injected into both the sheath and the subcutaneous 3. 17% (9) received no medication within the tendon sheath.

Group 1 had 47% good response
Group 2 had 50% good response
Group 3 had 70% good response. The results of this study suggest that true intra-sheath injection offers no apparent advantage over subcutaneous injection in the treatment of trigger digits (X-ray with contrast)

Hip

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Comments (imaging assessment)
Leopold⁸⁵ 2001 Cadaver Accuracy	Anterior 60% (9/15) Lateral 80% (12/15)	Anterior significantly riskier to the femoral artery/nerve than lateral
Kurup¹⁶ 2010 Clinical Accuracy	Anterolateral 65% (28/43)	Obesity, severe grade 4 arthritis with no joint space, and flexion deformity accounted for the majority of failed cases (needle position using image intensifier)
Ziv¹⁵ 2009 Clinical Accuracy	Lateral 78% (31/40)	In all 9 unsuccessful injections, the dye was located distal to the joint, along the more lateral aspect of the femoral neck (dye injection)
Diraçoğlu⁹ 2009 Clinical Accuracy	51% (29/57)	‘Backflow’ technique did not correlate with accurate placement (fluoroscopy and X-ray with contrast)

Trochanteric bursitis

Lead author Year Subject Study type	Accuracy % (proportion of bursae injected)	Clinical outcomes where relevant Comments (imaging assessment)
Cohen⁶⁰ 2005 Clinical Accuracy	45% (18/40)	Senior doctors 53% Junior doctors 36% (X-ray with contrast)
Cohen³⁷ 2009 Clinical Outcome	Landmark guided 33 vs Fluoroscopic guided 32	No differences in outcomes 3 months post-injection, 15 (47%) patients in LG and 13 (41%) in the FG continued to have a positive outcome

Knee

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Comments (imaging assessment)
Essenyel ⁸⁶ 2007 Cadaver Accuracy	Anterolateral 85% (39) Anteromedial No stat. diff.(39) Lateral midpatellar No stat diff. (39) Medial midpatellar 56% (39)	Anterolateral lower incidence of soft tissue infiltration. AL results not statistically significant compared to AM and LMP portals.
Jackson⁴ 2002 Clinical accuracy	Anterolateral 71% (57/80) Anteromedial 75% (60/80) Lateral midpatellar 93% (74/80) (240 ‘dry’ knees)	Hyaluronan study (X-ray fluoroscopy)
Luc⁸ 2006 Clinical Accuracy	97% (32/33) ‘dry’ knees with OA	Backflow confirmation technique for correct placement using landmarks verified in 32/33 by imaging (X-ray with contrast)
Toda²⁸ 2008 Clinical Accuracy	1. Modified Waddell approach (an anteromedial approach with manipulative ankle traction at 30° of knee flexion) 100% (11/11) 2. Anteromedial with the subjects seated 55% (6/11) 3. Lateral patellar 55% (6/11)33 patients with K–L grade IV OA

Hyaluronan study in 50 OA knee patients; recommends need for clinicians to change the approach employed for injections according to the severity of knee OA, based on Kellgren–Lawrence (K–L) radiographic grade (I = mild, IV = severe) (X-ray with contrast)

Ankle

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Comments
Heidari⁸⁷ 2010 Cadaver Accuracy	Anterolateral 86% (31/36) Anteromedial 78% (31/40)	Overall 82% accuracy, no statistical difference between approaches
Wisniewski²³ 2010 Cadaver Accuracy	Ultrasound guided 100% (20/20) vs Landmark guided 85% (17/20)

Subtalar

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Comments (imaging assessment)
Wisniewski 2010²³ Cadaver Accuracy	Ultrasound guided 90% (18/20) vs Landmark guided 35% (7/20)	Sinus tarsi injection
Kirk²⁴ 2008 Cadaver Accuracy	97% (58/60)	Injection into posterior subtalar joint Extravasation into the ankle in 14 and into the peroneal sheath in 2 (X-ray fluoroscopy)

Plantar fasciitis

Lead author Year Subject Study type	Study protocol	Clinical outcomes Comments (imaging assessment)
Yucel⁶³ 2009 Clinical Outcome	Palpation guided vs Ultrasound guided vs Scintigraphy guided (35 heels in 27 patients)	25 months post-injection all 3 groups improved significantly with no statistically significant differences between groups
Kane⁶¹ 2001 Clinical Outcome	Palpation guided (14) vs Ultrasound guided (10) (24 heels in 23 patients)	Ultrasound findings correlated with bone scintigraphy Ultrasound and palpation guided injection resulted in equally significant mean improvements.

Multiple joints in RA

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Clinical outcomes where relevant Comments (imaging assessment)
Cunnington³¹ 2010 Clinical Outcome	Ultrasound guided 83% vs Landmark guided 66% (total of 184 joints)	Inflammatory arthritis with an inflamed joint (shoulder, elbow, wrist, knee, or ankle) Equal clinical outcomes at 6 weeks (X-ray with contrast)
Lopes³² 2008 Clinical Outcome	Shoulder 82% Elbow 100% Wrist 97% MCP joints 97% Knee 100% Ankle 77% (total 232 joints)	Statistically significant improvement observed for all variables at 4 weeks (X-ray with contrast)

Multiple joints in multiple conditions

Lead author Year Subject Study type	Accuracy % (proportion of joints injected)	Clinical outcomes where relevant Comments (imaging assessment)
Koski²⁵ 2006 Clinical Accuracy	76–82% accuracy At 6/10 sites >80% (133 joints/tendon sheath)	Used a contrast medium method with a glucocorticoid-air-saline mixture and ultrasound imaging (GAS-graphy). Good reliability of the method; can be used in developing injection techniques and as an alternative for the radiographic contrast medium method in verifying successful injections
Jones¹ 1993 Clinical Accuracy and Outcome	Intra-articular 52% (56/108) Uncertain 19% (21/108) Extra-articular 29% (31/108)	A reduction of joint inflammation was associated with accuracy of injection. No effect seen for clinician seniority (X-ray with contrast)
Sibbitt³⁹ 2009 Clinical Outcome	Landmark guided vs Ultrasound guided (total of 148 joints)	Utilized novel one-handed reciprocating device. US guidance resulted in reduction in procedural pain, absolute pain scores at 2 week outcome and reduction in significant pain. US also increased detection of effusion by 200% volume of aspirated fluid by 337%

Caudal epidural

Lead author Year Subject Study type	Accuracy % (proportion entered ‘blind’)	Clinical outcomes where relevant Comments (imaging assessment)
Lewis¹² 1992 Clinical Accuracy	73% (19/26)	All 19 correctly placed had positive ‘whoosh’ test (no false positives) i.e. sound heard with stethoscope over sacrum as small amount of air injected (correct needle placement determined by epidurograph)

Aspiration studies

Lead author Year Subject Study type	Accuracy % (proportion of joints aspirated)	Clinical outcomes where relevant Comments (imaging assessment)
Raza⁵¹ 2003 Clinical Accuracy and Outcome	Landmark guided 32% (10/32) vs. Ultrasound guided 96% (30/31) End-point was successful aspiration from small joints	Ultrasound guidance allows needle placement within a small joint with significantly greater accuracy than a palpation-guided approach. When followed by lavage synovial fluid cells and diluted synovial fluid can be obtained from the majority of small joints. This has important research implications
Balint⁵² 2002 Clinical Accuracy and Outcome	Landmark guided 59% (10/17) vs. Ultrasound guided 97% (51/53) End-point was successful aspiration	Following US examination, aspiration was performed by a second rheumatologist based on the US localization of fluid or under direct US guidance. The mean volume of fluid obtained from successful aspirations was similar in both groups