Natalia R Chavez-Chiang’s research while affiliated with University of New Mexico and other places

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Publications (8)


Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?
  • Article

November 2011

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201 Reads

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132 Citations

Scandinavian Journal of Rheumatology

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L G Kettwich

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The present randomized controlled trial compared arthrocentesis of the effusive knee followed by corticosteroid injection performed by the conventional anatomic landmark palpation-guided technique to the same procedure performed with ultrasound (US) needle guidance. Sixty-four palpably effusive knees were randomized to (i) palpation-guided arthrocentesis with a conventional 20-mL syringe (22 knees), (ii) US-guided arthrocentesis with a 25-mL reciprocating procedure device (RPD) mechanical aspirating syringe (22 knees), or (iii) US-guided arthrocentesis with a 60-mL automatic aspirating syringe (20 knees). The one-needle two-syringe technique was used. Outcome measures included patient pain by the Visual Analogue Scale (VAS) for pain (0-10 cm), the proportion of diagnostic samples, synovial fluid volume yield, complications, and therapeutic outcome at 2 weeks. Sonographic guidance resulted in 48% less procedural pan (VAS; palpation-guided: 5.8 ± 3.0 cm, US-guided: 3.0 ± 2.8 cm, p < 0.001), 183% increased aspirated synovial fluid volumes (palpation-guided: 12 ± 10 mL, US-guided: 34 ± 25 mL, p < 0.0001), and improved outcomes at 2 weeks (VAS; palpation-guided: 2.8 ± 2.4 cm, US-guided: 1.5 ± 1.9 cm, p = 0.034). Outcomes of sonographic guidance with the mechanical syringe and automatic syringe were comparable in all outcome measures. US-guided arthrocentesis and injection of the knee are superior to anatomic landmark palpation-guided arthrocentesis, resulting in significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.


A Randomized Controlled Trial Evaluating the Cost-Effectiveness of Sonographic Guidance for Intra-Articular Injection of the Osteoarthritic Knee

November 2011

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90 Reads

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87 Citations

Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases

The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee. Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined. Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction (17)incostperpatientperyear,anda5817) in cost per patient per year, and a 58% (224) reduction in cost per responder per year for a hospital outpatient (P < 0.001). Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.


Nerve Blocks at the Wrist for Painful Injections of the Palm

June 2011

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35 Reads

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7 Citations

Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases

Injections into the palmar hand for trigger finger, palmar flexor tenosynovitis, and Dupuytren contracture can be very painful. This randomized, controlled study evaluated nerve block anesthesia at the wrist for prevention of procedural pain associated with painful injection of the palmar hand. Forty-seven corticosteroid injections for trigger fingers in 19 individuals were randomized to (1) anesthesia consisting of median and ulnar nerve block with 1% lidocaine anesthesia followed by standard injection or (2) standard injection alone using the 1-needle 2-syringe technique consisting of transthecal dilation of the synovial sheath with 0.5 mL 1% lidocaine with a mechanical syringe, the reciprocating procedure device, followed by injection with 20 mg triamcinolone acetonide. Baseline pain, needle insertion/sheath dilation pain, corticosteroid injection pain, resolution of trigger finger, and pain at outcome (2 weeks) were determined. Standard injection for trigger finger was associated with significant pain in 100% of subjects. Nerve blocks at the wrist provided effective anesthesia, resulting in a 56% reduction in injection pain compared with direct injection (P < 0.01). There was 100% resolution of trigger finger in both treatment groups. Pain at the 2-week outcome, reduction in pain from baseline, responders, and nonresponders were not statistically different (P > 0.3 for all). Eighty-eight percent of subjects preferred nerve block anesthesia to direct injection (P < 0.0001). Nerve block anesthesia at the wrist before palmar injection is preferred by patients and is highly effective in preventing pain associated with injection of the palmar hand for trigger finger and other painful hand procedures.


Figure 2. Sonographic Anatomy for Injection of the Carpal Tunnel  
Figure 4. Sonographic Needle Introduction
Figure 6. Corticosteroid Injection
Sonographically-Guided Hydrodissection and Corticosteroid Injection for Scleroderma Hand
  • Article
  • Full-text available

June 2011

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739 Reads

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40 Citations

Clinical Rheumatology

Scleroderma is associated with intractable hand pain from vasospasm, digital ischemia, tenosynovitis, and nerve entrapment. This study investigated the effect of hydrodissection of the carpal tunnel followed by corticosteroid injection for the painful scleroderma hand. Twenty-six consecutive subjects [12 with painful scleroderma hand and 14 with rheumatoid arthritis and carpal tunnel syndrome (RA/CTS)] underwent sonographically observed carpal tunnel hydrodissection with 3 ml of 1% lidocaine administered with a 25-gauge 1-in. needle on a 3-ml RPD mechanical syringe (reciprocating procedure device). After hydrodissection, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected. Baseline pain, procedural pain, pain at outcome, responders, therapeutic duration, and reinjection interval were determined. Hydrodissection and injection with corticosteroid significantly reduced pain scores by 67% in scleroderma (p < 0.001) and by 47% in RA/CT (p < 0.001). Scleroderma and RA/CTS were similar in outcome measures: injection pain (p = 0.47), pain scores at outcome (p = 0.13), responders (scleroderma, 83.3%; RA/CTS, 57.1%, p = 0.15), pain at 6 months (p = 0.15), and therapeutic duration (p = 0.07). Scleroderma patients responded better in time to next injection (scleroderma, 8.5 ± 3.0 months; RA/CTS, 5.2 ± 3.1 months, p = 0.03). Reduced Raynaud's attacks and healing of digital ulcers occurred in 83% of subjects. There were no complications. Hydrodissection with lidocaine followed by injection of triamcinolone reduces pain and vasomotor changes in the scleroderma hand. The mechanism may be a combination of hydrodissection-mediated mechanical freeing of entrapped arteries, nerves, and tendinous structures and corticosteroid-induced reduction of inflammatory vasospasm.

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The highly accurate anteriolateral portal for injecting the knee

March 2011

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3,497 Reads

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30 Citations

Sports Medicine Arthroscopy Rehabilitation Therapy & Technology

The extended knee lateral midpatellar portal for intraarticular injection of the knee is accurate but is not practical for all patients. We hypothesized that a modified anteriolateral portal where the synovial membrane of the medial femoral condyle is the target would be highly accurate and effective for intraarticular injection of the knee. 83 subjects with non-effusive osteoarthritis of the knee were randomized to intraarticular injection using the modified anteriolateral bent knee versus the standard lateral midpatellar portal. After hydrodissection of the synovial membrane with lidocaine using a mechanical syringe (reciprocating procedure device), 80 mg of triamcinolone acetonide were injected into the knee with a 2.0-in (5.1-cm) 21-gauge needle. Baseline pain, procedural pain, and pain at outcome (2 weeks and 6 months) were determined with the 10 cm Visual Analogue Pain Score (VAS). The accuracy of needle placement was determined by sonographic imaging. The lateral midpatellar and anteriolateral portals resulted in equivalent clinical outcomes including procedural pain (VAS midpatellar: 4.6 ± 3.1 cm; anteriolateral: 4.8 ± 3.2 cm; p = 0.77), pain at outcome (VAS midpatellar: 2.6 ± 2.8 cm; anteriolateral: 1.7 ± 2.3 cm; p = 0.11), responders (midpatellar: 45%; anteriolateral: 56%; p = 0.33), duration of therapeutic effect (midpatellar: 3.9 ± 2.4 months; anteriolateral: 4.1 ± 2.2 months; p = 0.69), and time to next procedure (midpatellar: 7.3 ± 3.3 months; anteriolateral: 7.7 ± 3.7 months; p = 0.71). The anteriolateral portal was 97% accurate by real-time ultrasound imaging. The modified anteriolateral bent knee portal is an effective, accurate, and equivalent alternative to the standard lateral midpatellar portal for intraarticular injection of the knee. ClinicalTrials.gov: NCT00651625.


The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee

February 2011

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41 Reads

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19 Citations

Rheumatology International

Although intraarticular injections are important to the management of rheumatoid arthritis, there are few studies regarding the cost-effectiveness of alternative injection techniques. This randomized controlled study addressed the cost-effectiveness of two different low-cost, anatomic landmark palpation-directed intraarticular injection techniques. Ninety-six symptomatic rheumatoid knees were randomized to two different low-cost, palpation-guided intraarticular injection techniques utilizing (1) a conventional syringe or (2) a mechanical syringe, the RPD (the reciprocating procedure device). Three milliliters of 1% lidocaine were used to anesthetize the synovial membrane, followed by arthrocentesis and hydrodissection, and injection of 80 mg of triamcinolone acetonide utilizing the one-needle two-syringe technique. Baseline pain, procedural pain, aspirated fluid volume, pain at outcome (2 weeks and 6 months), responders, reinjection rates, cost/patient/year, and cost/responder/year were determined. Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). Both techniques significantly reduced pain scores at outcome from baseline (P < 0.001). The mechanical syringe technique resulted in a greater volume of aspirated fluid (P < 0.01), a 38% reduction in procedural pain (P < 0.001), a 24% reduction in pain scores at outcome (P < 0.03), an increase in the responder rate (P < 0.025), 33% increase in the time to next injection (P < 0.001), 23% (35US)reductionincost/patient/yearforapatienttreatedinaphysicianoffice(P<0.001),2435 US) reduction in cost/patient/year for a patient treated in a physician office (P < 0.001), 24% reduction (26 US) in cost/patient/year for a hospital outpatient (P < 0.001), and 51% ($151 US) reduction in cost/responder/year (P < 0.001). The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee can be improved significantly with low-cost alternations in technique.


A Randomized Controlled Trial of the Cost-Effectiveness of Ultrasound-Guided Intraarticular Injection of Inflammatory Arthritis

November 2010

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65 Reads

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91 Citations

The Journal of Rheumatology

We studied whether sonographic needle guidance affected the outcomes of intraarticular (IA) injection for inflammatory arthritis. Joints with inflammatory arthritis (n = 244; 76% rheumatoid arthritis, 3% small joints, 51% intermediate, and 46% large) were randomized to injection by conventional palpation-guided anatomic injection (120 joints) or sonographic image-guided injection enhanced with a 1-handed reciprocating procedure device mechanical syringe (124 joints). A 1-needle, 2-syringe technique was used. After IA placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and triamcinolone acetonide was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined. Relative to conventional palpation-guided methods, sonographic guidance for injection of inflammatory arthritis resulted in an 81% reduction in injection pain (p < 0.001), 35% reduction in pain scores at outcome (p < 0.02), 38% increase in the responder rate (p < 0.003), 34% reduction in the non-responder rate (p < 0.003), 32% increase in therapeutic duration (p = 0.01), 8% reduction (7)incost/patient/year,anda337) in cost/patient/year, and a 33% (64) reduction in cost/responder/year for a hospital outpatient (p < 0.001). Sonographic needle guidance improves the performance, clinical outcomes, and cost-effectiveness of IA injections for inflammatory arthritis. (Clinical Trial Identifier NCT00651625).


Citations (8)


... It also appears to be useful in clinically suspected CTS when electrodiagnostic testing is normal [4]. US imaging of the median nerve has recently been shown to be of value in assessing the effectiveness of corticosteroid injection into the carpal tunnel for treatment of CTS by demonstrating reduction in the cross-sectional area of the median nerve [5]. Common anatomic anomalies in the carpal tunnel, such as a bifid median nerve, also can be detected [6]. ...

Reference:

Carpal Tunnel Injection: With or Without Ultrasound Guidance?
Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance [abstract]
  • Citing Article
  • January 2010

Arthritis & Rheumatology

... According to the literature, ultrasound guidance can potentially enhance the accuracy of injections by providing real-time visualization of the target area. [48][49][50][51] These studies showed that in-plane ultrasound-guided knee injections for the lateral suprapatellar approach are safe and effective compared to landmark palpation-guided techniques. These studies are relevant as ultrasound-guided arthrocentesis and injections significantly reduce pain, increase success rates and improve clinical outcomes. ...

Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?
  • Citing Article
  • November 2011

Scandinavian Journal of Rheumatology

... In the last few years, several studies have highlighted the advantages of imaging guides in joint infiltrations over blind maneuvers (Table 1) [111][112][113][114]. ...

A Randomized Controlled Trial Evaluating the Cost-Effectiveness of Sonographic Guidance for Intra-Articular Injection of the Osteoarthritic Knee
  • Citing Article
  • November 2011

Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases

... Although the WB is rarely used in rheumatology, sports medicine or family practice, this is common in hand surgery, orthopedic surgery, and emergency situations (6). Hematoma block (HB) is another method, in which a local anesthetic agent is injected in the joint and the fracture related hematoma. ...

Nerve Blocks at the Wrist for Painful Injections of the Palm
  • Citing Article
  • June 2011

Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases

... In a randomized study of Chavez-Chiang et al., 13 the results of US-guided anterolateral and midpatellar lateral access techniques were compared in terms of pain score; both techniques were equally effective. ...

The highly accurate anteriolateral portal for injecting the knee

Sports Medicine Arthroscopy Rehabilitation Therapy & Technology

... Adjunctive steroid or chemotherapeutic agent injections into the treated BNC have been employed to reduce recurrence, with varying levels of success. The role of these agents remains controversial [1,[4][5][6][7][8][9][10]. ...

The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee
  • Citing Article
  • February 2011

Rheumatology International

... Ultrasound-guided hydro-dissection in CTS individuals has only been the subject of a small number of clinical trials. DeLea et al. [33] employed ultrasound-guided HD (3 ml of 1% lidocaine) of entrapped structures within the carpal tunnel to treat twelve individuals with scleroderma of the hand, and they compared their results to those of a control group of fourteen individuals with rheumatoid arthritis-related CTS. The pain scores of those with RArelated CTS reduced by 47% from baseline at 2 weeks, while those with scleroderma decreased by 67% from baseline. ...

Sonographically-Guided Hydrodissection and Corticosteroid Injection for Scleroderma Hand

Clinical Rheumatology

... Moreover, its use avoids the logistical and financial burden of receiving injection guidance using conventional US which is only available at specialized centers and radiology departments. In a randomized controlled trial by Sibbit et al., the authors found that the use of conventional US-guidance was 8% more costeffective and had a 32% longer duration of pain reduction when compared to palpation-guided injections (23). Considering the degree of technical advancement of US technology since the time of this trial in 2009, P-US should perform at least as well as US when compared to palpation guidance. ...

A Randomized Controlled Trial of the Cost-Effectiveness of Ultrasound-Guided Intraarticular Injection of Inflammatory Arthritis
  • Citing Article
  • November 2010

The Journal of Rheumatology