Ultrasound-Guided Steroid Tendon Sheath Injections in Juvenile Idiopathic Arthritis: A 10-Year Single-Center Retrospective Study

SLR - August 2017 - Jason P. Havey

Residency Program: Hennepin County Medical Center, Minneapolis, MN

Podiatric Relevance: Juvenile Idiopathic Arthritis (JIA) is the most common rheumatic disease of childhood. The ankle is involved in 58 percent of cases among the pedal joints. Tenosynovitis is a common manifestation of JIA and often the culprit of ongoing clinical symptoms. Seventy-one percent of JIA patients with ankle inflammation have been found to have tenosynovitis. Ultrasound-guided injections can offer a more precise delivery of steroid into the sheath of the tendon allowing for safer, more effective pain relief.

Hypothesis: Ultrasound-guided injections to tendon sheaths is a safe and efficient technique to treat tenosynovitis in JIA patients.

Methods: This is a 10-year single-center retrospective review of all ultrasound-guided tendon sheath injections from May 2006 to April 2016. Inclusion criteria were any patient with a diagnosis of juvenile idiopathic arthritis and a request for tendon sheath injection from a rheumatologist. Patients were excluded if referral or procedural information was incomplete. Two investigators commented on the sonographic appearance of the tendon sheath prior to the procedure. Average age at time of procedure was nine years and eight months. Twelve hundred seventy-five total procedures with 926 tendon sheaths were injected.

Results: One hundred eighty-four females and 60 males were included in the study. The most commonly injected site was the ankle, and the posterior tibial tendon was most injected. Tendon sheath and joint were both injected at 296/308 visits vs. tendon sheath only in 12 visits. An average of three tendons were injected per visit. The mean injection index (InIx) was 0.765, indicating that clinical exam identified tenosynovitis accurately 77 percent of the time. One hundred forty-eight procedures (48 percent) had InIx of 1.0, meaning that requested injections were performed as ordered. In 42 procedures, no injection was warranted due to lack of signs of inflammation on ultrasound. 91.9 percent of procedures indicated peritendinous fluid and synovial sheath thickening. Two thirds of patients underwent general anesthesia for their procedure. Only 12.7 patients required repeat injections.

Conclusions: The authors note that it is only safe to inject a tendon sheath when peritendinous fluid is present. The authors of this study noted that for every 100 referrals for tendon sheath injection, 77 were performed. This is a safe treatment method with a high technical success rate. Injections can be painful and traumatizing to children, particularly if no therapeutic benefit is obtained and more injections are needed. Ultrasound guidance with good visualization of pathologic peritendinous fluid is beneficial for the patient suffering from tenosynovitis and can prevent harm to the tendon if no tenosynovitis is present.