Ultrasound evaluations and guided procedures of the painful joint arthroplasty

Abstract

The purpose of this article is to describe the use of ultrasound for the diagnosis and treatment of painful joint arthroplasty. Ultrasound plays a crucial role in the diagnosis of the painful joint arthroplasty, especially given its unique dynamic capabilities, convenience, and high resolution. Ultrasound guidance is also instrumental for procedures in both diagnosing and in select cases, treating the painful joint arthroplasty. Topics to be discussed in this article include trends in arthroplasty placement, benefits of the use of ultrasound overall, and ultrasound evaluation of periprosthetic joint infections. We will also review the sonographic findings with dissociated/displaced components and adverse reaction to metallic debris including metallosis, trunnionosis, and metal-on-metal pseudotumors. Additionally, we will discuss ultrasound evaluation of tendon pathologies with arthroplasties, including dynamic maneuvers to evaluate for tendon impingement/snapping. Finally, we will cover ultrasound-guided joint arthroplasty injection indications and precautions. Key points• Ultrasound is preferred over MRI in patients with joint arthroplasty and plays a crucial role in diagnosis, especially given its unique dynamic capabilities, convenience and high resolution.• It is especially beneficial for US-guided aspiration in periprosthetic joint infections; effectively used to evaluate periprosthetic fluid collections, facilitating differentiation between abscesses and aseptic collections, and tracking sinus tracts.• Recently, the diagnosis of periprosthetic joint infections has shifted focus to biomarkers in the periprosthetic fluid, specifically α-defensin, which has a high sensitivity and specificity for diagnosing infection.• Cutibacterium acnes is a major pathogen responsible for shoulder arthroplasty infections, often presenting with normal laboratory values and since slow growing, must be kept for a minimum of 14 days.

Update on Shoulder Arthroplasties with Emphasis on Imaging

“…US is highly useful in the evaluation of the rotator cuff integrity following shoulder arthroplasty and lacks the metallic artifact that occurs on MRI and CT (Figure 21B). US can also evaluate bursal fluid, joint effusion, synovitis, and osseous irregularity [39].…”

“…PJI of the shoulder has been reported in 1.1-4% of ATSA and in 3.8-18% of RTSAs [39,48,49], which may be complicated by the fact that RTSA is often used in re-vision surgeries, which are at a higher risk of PJI. The risk of PJI is three times higher in arthroplasties following trauma compared to elective arthroplasties and has been found to be 2.5 times more common in males compared to females [39,49]. Other risk factors include young age, smoking, and hemodialysis [7].…”

“…Cutibacterium acnes (C. acnes), formerly Propionibacterium acnes, is the other major organism which may be detected with shoulder arthroplasty infections (31-70% of PJI of the shoulder) and can occur up to two years post-operatively [48][49][50]. C. acnes is a non-spore-forming, anaerobic, Gram-positive bacillus commonly found in hair follicles, sebaceous glands deep in the dermis, conjunctiva, respiratory tract, gastrointestinal tract, and external auditory canal [7,39,49,50]. It often resides in a biofilm, where it is isolated from the patient's immune system, avoiding phagocytosis [49,50].…”

“…It often resides in a biofilm, where it is isolated from the patient's immune system, avoiding phagocytosis [49,50]. Patients often present with pain and stiffness, without fever, and with normal laboratory values, including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein [39,49,50]. Due to the slow rate of growth and often low concentration of the bacteria within the biofilm, cultures must be kept for a minimum of 14 days.…”

“…Positive cultures in the absence of clinical symptoms are not thought to indicate infection; 24-50% of shoulders with revision arthroplasties have been shown to be culturepositive, but true infection is suspected in only 5-25% of these cases [51]. Currently, joint fluid is often evaluated for the presence of α-defensin, an antimicrobial peptide released by neutrophils, which is highly sensitive and specific for PJI (85-100%) [39]. A variety of treatment options exists for PJI, including one-stage, two-stage, or three-stage revisions [47].…”