ORIGINAL ARTICLE Nr 2019;9 (3):328-337 Comparison of ultrasound-guided versus blind interventions for supraspinatus tendinopathy: a cadaveric study. F. Abat 1, J. Campos2, J. Torras3, M. Madruga3,4, G. Planells 3, A. Rodriguez-Baeza5 1 Sports Orthopaedic Department. ReSport Clinic. Universitat Autònoma Barcelona, Barcelona 2 Sports Medicine Department. ReSport Clinic. Universitat Autònoma Barcelona, Barcelona. Spain 3 Physiotherapy and Rehabilitation Department. ReSport Clinic. Universitat Autònoma Barcelona. Barcelona. Spain 4 University School of Health and Sport (EUSES), University of Girona, Girona, Spain. 5 Human Anatomy Unit. Department of Morphological Sciences. Faculty of Medicine. Universitat Autònoma Barcelona. Bellaterra, Barcelona. Spain CORRESPONDING AUTHOR: SUMMARY Ferran Abat Background. The treatment of supraspinatus tendinopathy remains a challenge for the Sports Orthopaedic Department. health professional. This study aims to analyze the precision of needle interventions in ReSport Clinic. Universitat Autònoma lesions of the supraspinatus tendon when conducting them in an ultrasound-guided or Barcelona, non-ultrasound guided (blind) manner. Barcelona, Spain Methods. Study on cadaver with infiltrations performed under ultrasound control or blind Passeig Fabra i Puig 47 after randomization of the parts and participants. Twenty fresh cadaveric shoulders and 30 08030 Barcelona. Spain. practitioners with experience using musculoskeletal ultrasound and doing needle interven- tions. Each practitioner performed 4 ultrasound-guided and 4 unguided punctures. This Phone: +34 932 778 709 provided 240 punctures that were analyzed in 3 different anatomical cuts, thus providing E-mail: abat@resportclinic.com a database of 720 measurements for statistical analysis. DOI: Results. Statistically significant differences were observed (p<0.0001) in the distance to 10.32098/mltj.03.2019.06 the bullet point between the ultrasound-guided and the non-guided infiltrations. It was estimated that the unguided punctures were performed on average 10mm farther from the LEVEL OF EVIDENCE: 2B bullet point than the ‘ultrasound-guided’ punctures. The ultrasound-guided punctures demonstrated 95% precision while the unguided punctures had a precision rate of 12.5% (p <0.0001). Conclusion. Interventions of the supraspinatus tendon should be performed in an ultra- sound-guided manner to facilitate administration of the treatment in the proper area. KEY WORDS injections; interventions; tendon; treatment; usget; ultrasound guided BACKGROUND cuff (RC) injury (Figure 1). Jeong et al. (9) has shown the The treatment of supraspinatus tendinopathy remains a anterior area of the SSP, at about 9-10mm posterior to the challenge for the health professional. The current literature biceps tendon, as the area at greatest risk of injury (Figures advocates for multidisciplinary work among physicians, 2A-B). physiotherapists and rehabilitators to treat this patholo- Until relatively recently, needle interventions had only been gy (1,2). Invasive therapies (in which the injured tendon is carried out blind (anatomical landmark-guided). Howev- punctured) either for the application of galvanic currents er, with the arrival of ultrasound and its rise, it has been (3,4), biological therapies (4,5) or analgesics (6,7,8) are a shown that using it improves precision in the infiltration widespread therapeutic tool today. procedure (10. Ultrasound provides an easy-to-use tool The supraspinatus tendon insertion area (SSP) at the level with high image quality, does not irradiate and has a moder- of footprint is the area most frequently affected in a rotator ate economic cost (11). Precision in carrying out injected 328 F. Abat, J. Campos, J. Torras, M. Madruga, G. Planells, A. Rodriguez-Baeza therapies should be the highest priority. Literature already point) with the aim of providing guidelines for action in reports that infiltrations that are not properly done in some future interventions. areas may worsen the symptoms or make the applied thera- py ineffective (12,13). Multiple treatments have been described that may be useful MATERIALS AND METHODS in the treatment of supraspinatus tendinopathy (4). The The Ethics and Experimentation Committee of our Univer- main basis of most of these treatments is that the product or sity (num. 03272015) approved the study and meet the ethi- technique to be applied must be administered in a specific cal standard of this journal (14). The study was carried out area of the tendon (area of injury). Mainly, these treatments in the dissection room of the Faculty of Medicine of our are with Platelet Rich Plasma (PRP), Ultrasound-guided university using 20 upper members from cadavers donated galvanic electrolysis (USGET), or corticosteroids (4,7,8). to science. All the donors were serologically tested to rule As far as the authors know, this is the first work that analyzes out infectious-contagious diseases (HIV, hepatitis B and the precision of ultrasound-guided and blind punctures hepatitis C) before starting the study. Of the 20 donors, 12 inside the supraspinatus tendon (area of injury or bullet were women and 8 men, with an average age of 82.3 years Figure 1. Coronal section of the glenohumeral joint showing the most relevant anatomical structures. Muscles, Ligaments and Tendons Journal 2019;9 (3) 329 US-guided vs blind interventions in supraspinatus tendinopathy Figure 2. A. Top view of the right supraspinous fossa where the tendons are identified Supraspinous and infraspinous. B. Coro- nal section of the gleno-humeral joint showing the prolongation of the supraspinatus muscle to its tendinous and insertion part. (range 71-100 years). There were 9 right shoulders and 11 muscle tendon to assess the usefulness of ultrasound. Ultra- left shoulders. sound examination was performed with a 5-16MHz linear The presence of scars and/or shoulder deformities that could array transducer in longitudinal and transversal view in a interfere with the results of the study was then assessed and real-time imaging mode in a standardized mode as described the upper limbs of the trunk were separated with scapu- by Rutten et al. (15). lo-thoracic disarticulation and clavicular sectioning near the With the help of 5ml luer-lock syringes with 21G needles of sternoclavicular joint. The upper extremities were stored 30 millimeters, a 1cc infiltration of colored natural latex was frozen at -40ºC for up to 2 hours before use. performed with randomization of the parts and the practi- To perform the study, each upper limb was placed in a tioners. Each practitioner conducted four ultrasound-guid- support that fixed the body of the scapula, thus exposing ed and four unguided interventions, each on a different the shoulder in an anatomical position. specimen, which made it possible to have a database of 240 Thirty practitioners performed the infiltrations. The prac- infiltrations. To assess infiltration precision, the anterior titioners had an average age of 36.9 years (range of 25 to part of the supraspinatus tendon (SSP) was considered the 59 years), experience of 6.9 years (range of 2 to 25 years) in bullet point, about 9 to 10mm posterior to the tendon of the invasive therapies with needles and average experience of long head of the biceps brachii muscle and centered on the 3.3 years (ranging from 1 to 15 years) in the use of musculo- thickness of the SSP. skeletal ultrasound. Once the infiltrations were done, the extremities were The practitioners were informed of the objective of the frozen at -40ºC for 1 month. Then, serial cuts, 1cm thick study. It was to perform infiltrations of the supraspinatus on the sagittal plane, were made with the help of a verti- 330 Muscles, Ligaments and Tendons Journal 2019;9 (3) F. Abat, J. Campos, J. Torras, M. Madruga, G. Planells, A. Rodriguez-Baeza cal band saw (Medoc BR 400, Medoc SA, Logroño, Spain) In the first place, since several punctures were made on the with a 4mm blade. Immediately after making the cuts, we same tendon, the contrast of the inclusion of said random proceeded to identify the three most significant serial cuts effect on the model was studied. Upon not obtaining statis- that allowed us to collect information on the location of the tically significant differences, the punctures were consid- latex and photograph it (digital camera Canon G11 5x - ered independent. A Kolmogorov-Smirnov test for normal- 6.1-30.5mm 1: 2.8-4.5). This information (30 practitioners x ity of each study and a descriptive analysis of the data were 8 infiltrations x 3 cuts) made for a database of 720 measure- performed. A box diagram of the mean distance to the ments (360 echoguided and 360 blind) for its subsequent center of the tendon and the table with the basic descrip- statistical analysis (Figure 3A-B) tive statistics (N, Medium, Std, Minimal, Q1, Medium, Q3, For the computer analysis of the images, Fiji software was Maximum and Missing) is presented depending on wheth- used. It is open source software focused on the analysis er the puncture was ultrasound-guided or unguided. The of biological images (º4). Using this software, the distance non-parametric contrast was performed for two indepen- between the point to be infiltrated (previously predeter- dent samples: The Wilcoxon test was done to check wheth- mined bullet point) and where the infiltration had been er there were differences in the distances to the center of done was calculated. the tendon between the punctures, ultrasound-guided and Statistical analysis was performed with SAS software v9.4 unguided. (SAS Institute Inc., Cary, NC, USA). The statistical decisions For the evaluation of precision, a descriptive analysis of the were made taking the value 0.05 as the level of significance. data was performed, presented with a precision bar chart and A validation of the internal consistency of the variables in the the table with the basic descriptive statistics (N, Percentage) database as well as the out-of-range values and missing values based on whether the puncture was ultrasound-guided or was done to fully ensure their reliability. The main response not. The Chi-Square independence test was carried out to variable was analyzed, this being the average distance to the check whether there were differences in the puncture preci- point of the tendon to be treated (bullet point) in the differ- sion distribution based on whether it was ultrasound-guid- ent anatomical cuts, categorizing this mean as precision. ed or not. The indicator, Precise (Completely Successful) Figure 3 A-B. Coronal section of the glenohumeral joint. In colors, the punctures are identified (colored latex). It can be observed that without the ultrasound control, the infiltrations were made in the SSE tendon as well as in adjacent structures. Muscles, Ligaments and Tendons Journal 2019;9 (3) 331 US-guided vs blind interventions in supraspinatus tendinopathy versus Not Precise (Partially Successful and Unsuccessful), ed puncture group had a maximum value of 9.5. All the was calculated. ultrasound-guided punctures were below the median of the unguided punctures. In ultrasound-guided punctures, we obtained an estimate RESULTS of the mean distances to the bullet point of 3.05, 95% CI= A great difference was observed in the punctures depend- [2.01, 4.09]. In contrast, we obtained an estimate in unguid- ing on whether they were ultrasound-guided or non-guid- ed punctures of the mean distances to the bullet point of ed (Figure 4). The median distance to the bullet point of 13.36, IC95%= [12.32, 14.4]. the 120 unguided punctures is 14 (Q1=6.47, Q3=16.2). It Statistically significant differences were detected (t Value is 2.91 in those that were Ultrasound-guided (Q1=2.47, = -13.8; p_value<0.0001) between ultrasound-guided Q3=3.41) (Table I). and unguided punctures. The difference between ultra- Statistically significant differences are observed (Wilcox- sound-guided and unguided punctures was -10.31mm, on Two-Sample Test = 21072.5; p_value<0.0001) in the IC95% = [- 11.78, -8.84]. This means that it was estimat- distance to the bullet point between those that were ultra- ed that the unguided punctures are performed on aver- sound-guided and those that were not. Specifically, it was age 10mm farther from the bullet point than the ultra- seen that the mean in the unguided was 10 units higher sound-guided punctures. than in ultrasound-guided. In addition, the median for the A great difference was observed when analyzing success- unguided puncture group was 14 when the ultrasound-guid- ful punctures Vs the unsuccessful in terms of whether it Supraspinatus 40 Distance to the bullet point 30 20 10 0 Non-guided Ultrasound-guided Figure 4. Bar chart showing the distance to the bullet point from the punctures. Table I. Distance of the ultrasound-guided or blind infiltrations to the bullet point. The number, mean, standard deviation as well as median, minimum, maximum and quartiles are shown. Distance to bullet point N Median Std Min Q1 Median Q3 Max Missing Unguided 120 13.36 8.1 1.91 6.47 14.00 16.20 37.64 0 US-guided 120 3.05 1.19 0.61 2.47 2.91 3.41 9.50 0 332 Muscles, Ligaments and Tendons Journal 2019;9 (3) F. Abat, J. Campos, J. Torras, M. Madruga, G. Planells, A. Rodriguez-Baeza was performed unguided or ultrasound-guided (Figure 5). Statistically significant differences were detected (t Value Imprecise punctures corresponded to unguided punctures. = 9.75; p value<0.0001) between ultrasound-guided and Most of the unguided punctures were imprecise, 74 punc- unguided punctures. The Odds Ratio for Precision = tures (61.67% of the total of unguided punctures). Most of Successful between ultrasound-guided and unguided punc- the ultrasound-guided punctures are successful, 114 punc- tures is 133, IC95% = [49.51, 357.29]. This means that the tures (95% of the total of ultrasound-guided punctures). Odds Ratio for Precision = Successful in ultrasound-guid- There were statistically significant differences (Chi-Square ed punctures was estimated at 133 times the odds in the Test = 166.87; p value<0.0001) in the distribution of the unguided. precision variable between the ultrasound-guided and unguided. Some 61.67% of unguided punctures were not precise. However, 95% of the ultrasound-guided punctures DISCUSSION were successful. The main objective of this study was to demonstrate the In unguided punctures, an estimate of the puncture percent- importance of the use of ultrasound in needle interventions age was obtained (with Precise = Successful) of 12.5%, 95% of the supraspinatus tendon. Our hypothesis that ultra- CI = [7.66%, 19.75%]. On the other hand, an estimate of sound-guided interventions demonstrate greater precision the puncture percentage was obtained in ultrasound-guid- than blind infiltrations has been validated. ed punctures (with Precise = Successful) of 95%, IC95%= Enough evidence can be found in the literature to support [89.28%, 97.75%] (Table II). the need to use ultrasound in shoulder infiltrations (4,17- Supraspinatus 100 80 Precision (in percentage) 60 40 20 0 Non-guided Ultrasound-guided Succesful Partially succesful Unsuccesful Figure 5. Bar chart showing the distance to precision of the ultrasound-guided or blind infiltrations. Table II. Precision of ultrasound-guided or blind infiltrations. Results classified as successful, partially successful or unsuccessful. Precision Successful Partially successful Unsuccessful Total N % N % N % N Unguided 15 15.50 31 25.83 74 61.67 120 US-guided 114 95 5 0 0 0 120 Muscles, Ligaments and Tendons Journal 2019;9 (3) 333 US-guided vs blind interventions in supraspinatus tendinopathy 19). In contrast, a recent Cochrane review concluded that since Abat et al. (3) advocate for amperages of between 2 the cost of ultrasound does not justify its use (20). Despite to 8 milliAmps while Arias-Buria et al. (31) use 350 micro- this, this study has important limitations such as obtaining a Amps in their study. Although there is a substantial debate conclusion based on a single study (17,21). about the use of corticosteroids in tendon pathology, they To date, it must be kept in mind that the clinical results are widely used (32,33). Currently, it is thought that the irri- of an invasive technique that is not performed in an ultra- gation implied in the use of corticosteroids in tendons no sound-guided manner cannot be analyzed. Multiple stud- longer justifies their use (7,34). ies show that, without ultrasound control, a very signifi- Another novel therapeutic approach includes the use of cant number of infiltrations end up outside the “target” hyaluronic acid (35,36), this treatment enhanced viability, site (8,17,19). Therefore, the clinical results do not proliferation and expression of collagen type I in tendon correlate with said procedure20. The current literature derived cells. already states that glenohumeral infiltrations administered Consensus on rotator cuff tears management was published in the correct area improve the clinical outcome (22,23), recently by Oliva et al. (37) and should be taked as acces- while infiltrations outside this area can even cause tissue sible guidelines in order to improve the quality of care and injuries (22). rationalize the use of the different treatment options. Several authors have written of rotator cuff lesions origi- The main limitation of the present study is the use of fresh nating in the anterior part of the cuff (insertion) spreading cadaveric specimens. In those specimens, muscular tension posteriorly with the passage of time (24,25). Recently, other during the injection cannot be determined by the practi- authors have shown that the degenerative lesions originat- tioner. Being cadavers of the advanced in age (average of ing in the infraspinatus tendon (ISP) spread towards the 82.3 years), the tendon of the supraspinatus can be found anterior aspect of the cuff (26,27). Subsequently, Kim et al., thin, making blind infiltration even more difficult. in an ultrasound study, described how a lesion of the RC Ultrasound-guided needle interventions have gained popu- generally occurred at the junction between the supraspina- larity in recent years (11). Although some studies indicate tus (SSP) and the infraspinatus (28). Finally, an important the lack of clinical differences that justify the cost of the recent study found that the main area of injury shown in ultrasound, no cost-effectiveness studies have so far been MRI is in the SSP insertion in a more anterior area, 9-10mm conducted (10,13,16-19,21,22) (Table III). For the time posterior to the biceps tendon (24). This has been the area being, we must rely on studies of the precision of ultra- that has been taken as an area to be treated in the present sound-guided versus blind infiltrations. They clearly favor study. Thus, the ability to puncture only in said area with the use of ultrasound to improve precision. and without ultrasound has been analyzed. In conclusion the present study clearly supports the use of Currently there are different therapeutic options for the ultrasound with needle procedures on the supraspinatus treatment of SSE tendinopathies (5). It is vital that their tendon, thus improving precision and making it possible to application be done correctly and in the precise area to be focus the treatment used in the correct area of injury. The treated. In a recent systematic review, authors such as Filar- novelty of this study resides in the evaluation of the injection do et al. found no differences between PRP infiltrations in therapy precision just on the spot of lesion (injured area), the SSE tendon or surgery (29). Then again, Fitzpatrick et al. making the treatment more specific and valuable. advocate for the use of leukocyte-rich PRP (LR-PRP) under ultrasound control in the treatment of these lesions in their meta-analysis (30). The ultrasound guided galvanic electrol- ACKNOWLEDGMENTS ysis technique (USGET) has also recently been proposed To the department of anatomy of the UAB (Campus Bellat- as a therapeutic option. It causes a controlled inflammatory erra) for its collaboration in the project, especially to Manel reaction in the tendon to trigger the regenerative process Querol for his involvement and diligence. (3,4). With subsequent eccentric work, the tissue is stim- Special mention to donors who have made this study possi- ulated to give mechanical support to the biological treat- ble with their altruism. We must also make mention of all ment. Arias-Buría et al. showed poor results with the use the colleagues who helped us during the infiltrations in the of electrolysis in tendinopathies of the supraspinatus (31). cadaverous parts. We are also grateful to Eric L. Goode for The difference in applied intensity should be highlighted his help in editing the manuscript. 334 Muscles, Ligaments and Tendons Journal 2019;9 (3) F. Abat, J. Campos, J. Torras, M. Madruga, G. Planells, A. Rodriguez-Baeza Table III. Literature review of ultrasound versus blinded injections around the shoulder. (GH = glenohumeral, US = Ultrasound, RCT = Randomized Controled Trial) Blinded versus Ultrasound Guided Injections Lead Author Year N Treatment area Treatment aplied Imaging Used Results Study Design Balint38 2002 6 GH joint Fluid Aspiration US / Blinded US superior to blinded Cohort Naredo 39 2004 41 Sub-acromial Corticosteroid US / Blinded US higher accuracy Cohort Lee 40 2009 43 GH joint Corticosteroid US / Blinded US obtain greater clinical RCT improvement Soh18 2011 101 Sub-acromial Corticosteroid US / Blinded US obtain greater clinical Sist. review improvement Patel22 2012 80 GH joint Cadaveric Study US / Blinded US higher accuracy Cohort Mattie 13 2015 GH joint Diagnostic Fluoroscopy / Image guided better results Cohort 162 contrast fluid Blinded Raeissadat23 2016 41 GH joint Corticosteroid US / Blinded US obtain greater clinical RCT improvement Cole41 2016 56 Sub-acromial Corticosteroid US / Blinded No differences in the RCT clinical outcome REFERENCES 1. 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