Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part VI, foot and ankle

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Abstract

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.

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Most cited references 82

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Abstract: found
Article: not found

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.

Brooke Coombes, Leanne Bisset, Bill Vicenzino (2010)

Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection. We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported. 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise. Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy. None. Copyright © 2010 Elsevier Ltd. All rights reserved.

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Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial.

Robert de Vos, Adam Weir, Hans van Schie … (2010)

Tendon disorders comprise 30% to 50% of all activity-related injuries; chronic degenerative tendon disorders (tendinopathy) occur frequently and are difficult to treat. Tendon regeneration might be improved by injecting platelet-rich plasma (PRP), an increasingly used treatment for releasing growth factors into the degenerative tendon. To examine whether a PRP injection would improve outcome in chronic midportion Achilles tendinopathy. A stratified, block-randomized, double-blind, placebo-controlled trial at a single center (The Hague Medical Center, Leidschendam, The Netherlands) of 54 randomized patients aged 18 to 70 years with chronic tendinopathy 2 to 7 cm above the Achilles tendon insertion. The trial was conducted between August 28, 2008, and January 29, 2009, with follow-up until July 16, 2009. Eccentric exercises (usual care) with either a PRP injection (PRP group) or saline injection (placebo group). Randomization was stratified by activity level. The validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, which evaluated pain score and activity level, was completed at baseline and 6, 12, and 24 weeks. The VISA-A score ranged from 0 to 100, with higher scores corresponding with less pain and increased activity. Treatment group effects were evaluated using general linear models on the basis of intention-to-treat. After randomization into the PRP group (n = 27) or placebo group (n = 27), there was complete follow-up of all patients. The mean VISA-A score improved significantly after 24 weeks in the PRP group by 21.7 points (95% confidence interval [CI], 13.0-30.5) and in the placebo group by 20.5 points (95% CI, 11.6-29.4). The increase was not significantly different between both groups (adjusted between-group difference from baseline to 24 weeks, -0.9; 95% CI, -12.4 to 10.6). This CI did not include the predefined relevant difference of 12 points in favor of PRP treatment. Among patients with chronic Achilles tendinopathy who were treated with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity. clinicaltrials.gov Identifier: NCT00761423.

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One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial.

J. de Visscher, Marienke van Middelkoop, Johannes Tol … (2011)

Achilles tendinopathy is a common disease among both athletes and in the general population in which the use of platelet-rich plasma has recently been increasing. Good evidence for the use of this autologous product in tendinopathy is limited, and data on longer-term results are lacking. To study the effects of a platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy at 1-year follow-up. Randomized controlled trial; Level of evidence, 1. Fifty-four patients, aged 18 to 70 years, with chronic tendinopathy 2 to 7 cm proximal to the Achilles tendon insertion were randomized to receive either a blinded injection containing platelet-rich plasma or saline (placebo group) in addition to an eccentric training program. The main outcome was the validated Victorian Institute of Sports Assessment-Achilles score. Patient satisfaction was recorded and ultrasound examination performed at baseline and follow-up. The mean Victorian Institute of Sports Assessment-Achilles score improved in both the platelet-rich plasma group and the placebo group after 1 year. There was no significant difference in increase between both groups (adjusted between-group difference, 5.5; 95% confidence interval, -4.9 to 15.8, P = .292). In both groups, 59% of the patients were satisfied with the received treatment. Ultrasonographic tendon structure improved significantly in both groups but was not significantly different between groups (adjusted between-group difference, 1.2%; 95% confidence interval, -4.1 to 6.6, P = .647). This randomized controlled trial showed no clinical and ultrasonographic superiority of platelet-rich plasma injection over a placebo injection in chronic Achilles tendinopathy at 1 year combined with an eccentric training program.

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Author and article information

Contributors

Luca Maria Sconfienza:

ORCID: http://orcid.org/0000-0003-0759-8431

io@lucasconfienza.it

Journal

Journal ID (nlm-ta): Eur Radiol

Journal ID (iso-abbrev): Eur Radiol

Title: European Radiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0938-7994

ISSN (Electronic): 1432-1084

Publication date (Electronic): 25 August 2021

Publication date PMC-release: 25 August 2021

Publication date (Print): 2022

Volume: 32

Issue: 2

Pages: 1384-1394

Affiliations

[1 ]GRID grid.417776.4, Unit of Diagnostic and Interventional Radiology, , IRCCS Istituto Ortopedico Galeazzi, ; Via Riccardo Galeazzi 4, 20161 Milan, Italy

[2 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Dipartimento di Scienze Biomediche per la Salute, , Università degli Studi di Milano, ; Milan, Italy

[3 ]Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, Heerlen, Brunssum, Kerkrade, the Netherlands

[4 ]GRID grid.10776.37, ISNI 0000 0004 1762 5517, Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, , Università degli Studi di Palermo, ; Palermo, Italy

[5 ]GRID grid.144756.5, ISNI 0000 0001 1945 5329, Hospital Universitario 12 de Octubre, ; Madrid, Spain

[6 ]St Luke’s Radiology Oxford Ltd, Oxford, UK

[7 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, University of Oxford, ; Oxford, UK

[8 ]GRID grid.414055.1, ISNI 0000 0000 9027 2851, Department of Radiology, , Auckland City Hospital, ; Auckland, New Zealand

[9 ]Department of Radiology, Hospital Vithas Nueve de Octubre, Valencia, Spain

[10 ]GRID grid.5395.a, ISNI 0000 0004 1757 3729, Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, , University of Pisa, ; Pisa, Italy

[11 ]GRID grid.419038.7, ISNI 0000 0001 2154 6641, Diagnostic and Interventional Radiology, , IRCCS Istituto Ortopedico Rizzoli, ; Bologna, Italy

[12 ]Analytic Imaging, Edinburgh, UK

[13 ]Ospedale Evangelico Betania, Napoli, Italy

[14 ]Clinica di Radiologia EOC IIMSI, Lugano, Switzerland

[15 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, School of Biomedical Engineering & Imaging Sciences, , King’s College London, ; London, UK

[16 ]Studio MSK, Belluno, Italy

[17 ]GRID grid.414651.3, ISNI 0000 0000 9920 5292, Hospital Universitario Donostia, ; San Sebastian, Spain

[18 ]Dipartimento di Diagnostica per Immagini, Pineta Grande Hospital, Castel Volturno, Italy

[19 ]MSK Radiology Services, Heraklion, Crete, Greece

[20 ]GRID grid.106023.6, ISNI 0000 0004 1770 977X, Hospital General Universitario de Valencia, ; Valencia, Spain

[21 ]GRID grid.5216.0, ISNI 0000 0001 2155 0800, 2nd Department of Radiology, University General Hospital “ATTIKON” Medical School, , National and Kapodistrian University of Athens, ; Haidari, Athens, Greece

[22 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Dipartimento di Scienze Biomediche per la Salute, , Università degli Studi di Milano, ; Milan, Italy

[23 ]GRID grid.24029.3d, ISNI 0000 0004 0383 8386, Cambridge University Hospitals, ; Cambridge, UK

[24 ]GRID grid.464636.5, ISNI 0000 0000 9898 1804, Mid Cheshire Hospitals NHS Foundation Trust, ; Cheshire, UK

[25 ]Leeds Teaching Hospitals, Leeds, UK

[26 ]GRID grid.420545.2, ISNI 0000 0004 0489 3985, Guy’s and St Thomas’ Hospitals, ; London, UK

[27 ]Department of Radiology, Special Hospital for Orthopedic Surgery and Traumatology, St. Erazmo –, Ohrid, North Macedonia

[28 ]GRID grid.7858.2, ISNI 0000 0001 0708 5391, Ss. Cyril and Methodius University of Skopje, ; Skopje, North Macedonia

[29 ]GRID grid.417895.6, ISNI 0000 0001 0693 2181, Imperial College Healthcare NHS Trust, ; London, UK

[30 ]GRID grid.5361.1, ISNI 0000 0000 8853 2677, Department of Radiology, , Medical University Innsbruck, ; Innsbruck, Austria

[31 ]GRID grid.410556.3, ISNI 0000 0001 0440 1440, Oxford Musculoskeletal Radiology, , Oxford University Hospitals, ; Oxford, UK

[32 ]Hospital Universitario Son Llatzer, Palma, Spain

[33 ]GRID grid.414429.e, ISNI 0000 0001 0163 5700, Hospital da Luz, Musculoskeletal Imaging Unit, ; Lisbon, Portugal

[34 ]AIRC, Advanced Imaging Research Consortium, Lisbon, Portugal

[35 ]GRID grid.15667.33, ISNI 0000 0004 1757 0843, Division of Interventional Radiology, , Istituto Europeo di Oncologia, ; Milan, Italy

[36 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Department of Oncology and Hemato-Oncology, , University of Milano, ; Milan, Italy

[37 ]Oxford Musculoskeletal Radiology, Oxford, UK

[38 ]GRID grid.439664.a, ISNI 0000 0004 0368 863X, Buckinghamshire Healthcare NHS Trust, ; Aylesbury, UK

[39 ]GRID grid.6363.0, ISNI 0000 0001 2218 4662, Department of Radiology, , Charité-Universitätsmedizin Berlin, ; Berlin, Germany

[40 ]GRID grid.411646.0, ISNI 0000 0004 0646 7402, Department of Radiology, , Herlev Gentofte Hospital, ; Herlev, Denmark

[41 ]Hospital de Loulé, Loulé, Portugal

[42 ]GRID grid.4495.c, ISNI 0000 0001 1090 049X, Department of Oral Surgery, , Wroclaw Medical University, ; Wroclaw, Poland

[43 ]Department of Radiology, Ospedale Evangelico Internazionale, Genoa, Italy

[44 ]GRID grid.413176.6, ISNI 0000 0004 1768 9334, Ribera Povisa Hospital, ; Vigo, Spain

[45 ]GRID grid.415131.3, ISNI 0000 0004 1767 2903, Post Graduate Institute of Medical Education & Research (PGIMER), ; Chandigarh, India

[46 ]Indywidualna Praktyka Lekarska Magdalena Posadzy, Poznan, Poland

[47 ]GRID grid.45083.3a, ISNI 0000 0004 0432 6841, Department of Radiology, , Lithuanian University of Health Sciences, ; Kaunas, Lithuania

[48 ]GRID grid.29524.38, ISNI 0000 0004 0571 7705, Institute of Radiology, , University Medical Centre Ljubljana, ; Zaloska 7, 1000 Ljubljana, Slovenia

[49 ]GRID grid.8954.0, ISNI 0000 0001 0721 6013, Faculty of Medicine, , University of Ljubljana, ; Ljubljana, Slovenia

[50 ]GRID grid.5606.5, ISNI 0000 0001 2151 3065, Department of Health Sciences, , University of Genova, ; Genoa, Italy

[51 ]GRID grid.410345.7, ISNI 0000 0004 1756 7871, IRCCS Ospedale Policlinico San Martino, ; Genova, Italy

[52 ]GRID grid.420022.6, ISNI 0000 0001 0723 5126, Department of Radiology, , AUVA Trauma Center Vienna, ; Vienna, Austria

[53 ]GRID grid.5841.8, ISNI 0000 0004 1937 0247, Radiology Dpt. MSK Unit. Hospital Clinic (CDIC), , University of Barcelona (UB), ; Barcelona, Spain

[54 ]University Institute of Radiology, Skopje, Macedonia

[55 ]GRID grid.7858.2, ISNI 0000 0001 0708 5391, Ss. Cyril and Methodius University in Skopje, ; Skopje, Macedonia

[56 ]Radiology Department, Hospital ICOT Ciudad de Telde, Las Palmas, Spain

[57 ]GRID grid.10373.36, ISNI 0000000122055422, Department of Medicine and Health Sciences, , University of Molise, ; Campobasso, Italy

[58 ]Varelli Institute, Naples, Italy

[59 ]GRID grid.452818.2, ISNI 0000 0004 0444 9307, Department of Radiology, , Sint Maartenskliniek, ; Nijmegen, The Netherlands

Author information

Luca Maria Sconfienza http://orcid.org/0000-0003-0759-8431

Article

Publisher ID: 8125

DOI: 10.1007/s00330-021-08125-z

PMC ID: 8794903

PubMed ID: 34432122

SO-VID: ccd92fe6-6962-4b66-92d2-edfbf6b9108f

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 27 March 2021

Date accepted : 7 June 2021

Funding

Funded by: Università degli Studi di Milano

Open Access :

Open access funding provided by Università degli Studi di Milano within the CRUI-CARE Agreement.

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ScienceOpen disciplines: Radiology & Imaging

Keywords: interventional radiology,ultrasonograph,ankle,foot,achilles tendon

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ScienceOpen disciplines: Radiology & Imaging

Keywords: interventional radiology, ultrasonograph, ankle, foot, achilles tendon

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part VI, foot and ankle

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Abstract

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Most cited references 82

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.

Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial.

One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial.

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