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In-Plane Ultrasound-Guided Knee Injection Through a Lateral Suprapatellar

Approach: A Safe Technique

Article  in  Ultrasound Quarterly · May 2017

DOI: 10.1097/RUQ.0000000000000288

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 ORIGINAL RESEARCH

In-Plane Ultrasound-Guided Knee Injection Through a

Lateral Suprapatellar Approach
A Safe Technique
Francisco A. Chagas-Neto, MD, PhD,*† Atul K. Taneja, MD,‡ Everaldo Gregio-Junior, MD, PhD,§
and Marcello H. Nogueira-Barbosa, MD, PhD§

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performed in radiology departments as part of computed to-
Purpose: This study aims to describe a technique for in-plane
mography (CT) and magnetic resonance (MR) arthrographies.2
ultrasound-guided knee arthrography through a lateral suprapatellar
There have been an increasing number of image-guided
approach, reporting its accuracy and related complications.

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procedures lately offering safer, comfortable, and more effi-
Methods: A retrospective search was performed for computed tomog-
cient approaches to patients when compared with surgery or
raphy and magnetic resonance reports from June 2013 through June
nonguided (blinded) procedures.3 Fluoroscopy and CT have
2015. Imaging studies, puncture descriptions, and guided-procedure
conventionally been used for many articular injections on sites

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images were reviewed along with clinical and surgical history. A
such as the shoulder, hip, wrist, and ankle.4,5 On the other hand,
fellowship-trained musculoskeletal radiologist performed all proce-
ultrasound-guided injections permit direct visualization of the
dures under sterile technique and ultrasound guidance with the probe
needle tip with real-time articular filling of contrast solution,
in oblique position on the lateral suprapatellar recess after local anesthe-
without requiring radiation. Ultrasound therefore has a signifi-
sia with the patient on dorsal decubitus, hip in neutral rotation, and 30 to
'S
cant advantage when compared with other methods, especially
45 degrees of knee flexion.
when used in pediatric patients.2,6
Results: A total of 86 consecutive subjects were evaluated (mean,
Because the knee presents a large articular cavity size,
55 years). All subjects underwent intra-articular injection of contrast,
the majority of these procedures are performed blinded, through
which was successfully reached in the first attempt in 94.2% of the pro-
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a classical lateral parapatellar approach, using manual patellar
cedures (81/86), and in the second attempt in 5.8% (5/86) after needle
subluxation. Alternatively, suprapatellar, medial parapatellar,
repositioning without a second puncture. There were no postprocedural
or medial infrapatellar approaches may be used.7 There are only
reports of regional complications at the puncture site, such as signifi-
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2 studies on approaching knee injections through its lateral

cant pain, bleeding, or vascular lesions.
suprapatellar region,8,9 but none of them aimed for arthrograms.
Conclusions: Our study demonstrates that in-plane ultrasound-guided
The purpose of this study is to describe a technique for
injection of the knee in semiflexion approaching the lateral suprapatellar
in-plane ultrasound-guided knee arthrography through a lateral
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recess is a safe and useful technique to administer intra-articular contrast

suprapatellar approach. We will also report the technique's
solution, as an alternative method without radiation exposure.
accuracy for cavity distension and related complications.
Key Words: knee, arthrography, ultrasound-guided, CT, MR
(Ultrasound Quarterly 2017;33: 139–143)
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MATERIALS AND METHODS

I ntra-articular knee injections are routinely performed in the
clinical setting for a wide range of diagnostic and thera- Subject Selection and Clinical Information
A

peutic reasons; most reasons are related to steroids and
viscosuplementation.1 In addition, articular injections are
Received for publication September 26, 2016; accepted January 5, 2017.
*Radiology Department, Centro Universitário Christus; †Radiology Department,
Hospital Antônio Prudente, Fortaleza, CE; ‡Musculoskeletal Radiology, Hos-
pital do Coração and Teleimagem, São Paulo, SP; and §Radiology Division
Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo,
Ribeirão Preto, SP, Brazil.
The authors declare no conflict of interest.
Address correspondence to: Atul K. Taneja, MD, Hospital do Coração and
Teleimagem, Av. Des. Eliseu Guilherme, N. 69, 7. Andar, São Paulo – SP,
Brazil CEP 04004–030 (e‐mail: tanejamsk@gmail.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/RUQ.0000000000000288
The institutional review board approved this study with
exemption for informed consent. A Boolean retrospective search
in radiology information systems software was performed for
CT and MR reports from June 2013 through June 2015, using
the search terms knee arthro-CT, knee arthro-MR, ultrasound-
guided knee puncture, and ultrasound-guided knee arthrography.
Imaging studies and reports as well as puncture descriptions and
guided-procedure imaging were reviewed along with clinical and
surgical history.
Subjects with incomplete puncture descriptions or clinical
data (when the description made no reference to the number of
punctures attempted or presence/absence of complications)
were excluded (a total of 17 cases).

Ultrasound Quarterly • Volume 33, Number 2, June 2017 www.ultrasound-quarterly.com 139

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Chagas-Neto et al
FIGURE 1. A 35-year-old woman; longitudinal ultrasound image of suprapatellar region with knee in extension shows collapsed
suprapatellar articular recess (arrow).
Puncture Technique
Each puncture was performed with the patient on dorsal
decubitus (supine), with the hip in neutral rotation and 30 to
45° degrees of knee flexion. The degree of flexion was defined
by direct and clear visualization of the lateral suprapatellar re-
cess, even if minimal amount of intra-articular fluid was present
(Figs. 1 and 2). Patients with large joint effusion had the fluid as-
pirated before the contrast solution injection (a total of 23 cases).
A fellowship-trained musculoskeletal radiologist with
5 years of experience performed all punctures. The knees were
examined using a linear probe (10–12 MHz), with gain, depth,
'S
and frequency rate parameters adjusted to optimize the procedure.
The puncture was performed under sterile technique and
ultrasound guidance with the probe in an oblique position on
the lateral suprapatellar recess of the knee (Fig. 3) externally
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to the quadriceps tendon, with a 22-Gauge needle (0.70 
30 mm) after local anesthesia (lidocaine 1%). The needle
reached the articular cavity after being accompanied through
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its entire tract under ultrasound direct visualization (longitu-
dinal technique – in plane, Fig. 4). While deepening the nee-
dle, particular attention was paid to avoiding damage to the
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quadriceps tendon, suprapatellar, and prefemoral fat pads as
well as chondral surfaces. After reaching the articular cavity,
the needle position was checked by anesthetics effusion,
followed by injection of 40 mL of diluted contrast solution
(25% of iodinated contrast – 10 mL). Therefore, local anes-
thesia and contrast were administrated using only 1 puncture.
U
A
FIGURE 2. A 35-year-old woman; same patient as in Figure 1—longitudinal ultrasound image of suprapatellar recess with 30 to
45° degrees of knee flexion demonstrates a small amount of fluid accumulation (arrow) serving as acoustic window to direct puncture
of articular cavity.
140 www.ultrasound-quarterly.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Ultrasound Quarterly • Volume 33, Number 2, June 2017
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Successful administration of the diluted intra-articular
contrast solution was considered after complete filling of the
cavity under direct ultrasound identification (Fig. 5).
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All procedures lasted approximately 10 to 15 minutes
and were performed in an ultrasound room annex of the CT
or MR room.
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Imaging Studies and Clinical Data Review
All imaging studies performed after ultrasound-guided
arthrographic procedures were reviewed, searching for com-
plications on puncture sites, such as bleeding, vascular and
neural lesions, or deep-structure damages (tendons, ligaments,
and cartilage).
Procedure reports and follow-up clinical and surgical
charts (if available) were also reviewed, assessing for imme-
diate or late complications related to the ultrasound-guided
procedure such as bleeding, significant pain, paresthesia, syncope,
allergic reactions, fever, or infectious signs.
RESULTS
Of a total of 103 consecutive subjects, 17 subjects were
excluded. Of 86 subjects included, 57% (49/86) were women
and 43% (37/86) men, with a mean age of 55 years (range,
16–78 years); 56% (48/86) of the injections were performed
on the right knee and 44% (38/86) of them on the left knee.
The main clinical indications for arthro-CT were patients
who had a contraindication for MR due to pacemaker, cochlear
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly • Volume 33, Number 2, June 2017
FIGURE 3. A 49-year-old man—left knee arthro-CT volume
rendering reconstruction illustrating the ultrasound transducer
position during the procedure by the lateral suprapatellar in
plane technique. Note: L (lateral); S (superior).
implant, claustrophobia in patients who did not agree to
undergo anesthesia (38 cases), doubtful meniscal lesions in
MR (16 cases), meniscal postoperative evaluation (14 cases),
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osteochondral lesions (11 cases), and precise measurement
of chondral lesions to the preoperative mosaicoplasty plan-
ning (7 cases).
All subjects underwent intra-articular contrast injection,
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which was successfully performed in the first attempt in
94.2% (81/86) of cases, and during the second attempt in
5.8% (5/86) after needle repositioning. In this latter subgroup,
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the needle tip was initially located within the prefemoral fat
pad. After such identification with visualization of contrast
accumulation (Fig. 6), the needle was pulled and repositioned
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without the need for a second puncture.
There were no reports of postprocedural regional compli-
cations at the puncture site such as significant pain, bleeding, or
vascular lesions. In addition, CT and MR performed after the
guided procedure did not detect any damage to deep structures,
U
A
FIGURE 4. A 48-year-old man—ultrasound image presenting the entire in-plane needle with distal needle tip inside articular
recess (arrow).
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Lateral Suprapatellar Approach for Knee Injection
neither in the needle tract nor in affected tendons, ligaments,
or cartilage.
A total of 80% of subjects (69/86) underwent arthro-
scopic surgery for clinical indications within 30 days of
the arthrography, which also confirmed the absence of
related complications.
DISCUSSION
Intra-articular injections are required for a wide range of
procedures performed by orthopedic surgeons, rheumatologists,
and radiologists. Senior physicians frequently perform blinded
procedures under physical examination with an accuracy rang-
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ing from 55% to 100% regarding effective approach of the
articular cavity.10 Besides the access chosen and personal
experience, such range may be due to patient-related consti-
tutional factors and articular abnormalities.1
Another important factor is the length of experience of
the performing physician. Usually, the learning curve of the
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blinded technique is longer than any imaging-guided tech-
nique. Curtiss et al8 tested the influence of experience time
in accuracy to blinded versus ultrasound-guided articular punc-
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tures. The authors concluded that, besides increasing overall
success of the procedure under ultrasound guidance, length of
experience did not have a significant influence with an accuracy
of 100%. On the other hand, blinded technique performed by
less experienced professionals had lower rates of accuracy,
varying from 55% to 75%.8
Different imaging methods have been used to guide injec-
tion procedures including fluoroscopy, CT, and ultrasound.3–6,11–13
Although effective, the first 2 methods present many disad-
vantages such as radiation, high cost, iodinated-contrast req-
uisition to confirm intra-articular positioning, not flexible,
and requirement of preprepared procedure rooms.8 On the
other hand, ultrasound does not use radiation; equipment are
low cost and highly accessible; portable, allowing them to
be moved to different sectors inside a health facility; do not
require preprepared rooms; do not need iodinated contrast
confirmation; and allow for direct visualization of real-time
articular cavity filling.8
Some studies have compared the accuracy of using blinded
versus ultrasound-guided knee puncture techniques.3,8,10,14–16
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Chagas-Neto et al Ultrasound Quarterly • Volume 33, Number 2, June 2017

FIGURE 5. A 48-year-old man—longitudinal ultrasound image of suprapatellar recess during the injection showing progressive filling of

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the articular recess with contrast solution. The needle is seen at the tip of the arrow.

In the review by Berkoff et al,3 blinded procedures had the The majority of studies using a lateral suprapatellar
accuracy of 77.8%, whereas ultrasound-guided had 95.8%. approach were performed with the knee in full extension, pro-
The authors concluded that ultrasound guidance increased moting articular fluid redistribution and reducing the amount to
accuracy of knee injections, with improved clinical outcomes be used as acoustic window.9 Ike et al22 showed that quadriceps

and decreased health system costs. Sibbitt et al16 reported in a
randomized controlled trial a decrease of pain during the in-
jection, with better clinical outcomes and cost-effectiveness
of ultrasound-guided injections in subjects with knee osteoar-
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contraction while the knee is in full extension might be useful to
increase the amount of fluid at the suprapatellar recess.
We found only 2 articles describing similar techniques to
that which we report in this article. None reported results for

thritis. In another study by the same authors, ultrasound was
tested to guide knee arthrocentesis, followed by steroid injec-
tion. They found a decrease of pain in 48% of subjects, with a
larger amount of aspirated fluid, resulting in more effective
'S
articular decompression.17 Hurdle et al18 reported a case of
an obese patient who previously underwent 4 steroid injec-
tions under blinded technique without relief of symptoms,
which were reverted after ultrasound-guided injection with
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minimum discomfort during the procedure and with complete
relief of pain.
In the current study, we retrospectively evaluated the
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arthrographic studies. In Curtiss et al,8 cadaveric specimens
under a 20-degree flexion of the knee were used, but all fluid
was previously aspirated, thus not translating to the clinical
setting where a fluid window is targeted to perform the injec-
tion under direct visualization. In the study by Park et al,23
lateral suprapatellar, medial patellar, and lateral patellar ap-
proaches were tested with the knee in 15 to 30 degrees of
flexion. This study presented the same technique of this cur-
rent study for steroid injections; however, their subject cohort
was restricted to Kellgren-Lawrence grade II and III osteo-
arthritis without joint effusion, defined by maximum thick-

accuracy of ultrasound-guided injection of the knee using a
semiflexion position and lateral suprapatellar approach. The
lateral suprapatellar recess accumulates most of the fluid dur-
ing supine position, even if only a physiologic amount.19,20
TH
ness of fluid in suprapatellar less than 4.0 mm. Such criteria
do not allow extrapolating reproducibility of results to other
subgroups, especially those with large articular effusions.
Finally, it has also been described in the literature that there

Previous studies evaluated ultrasound-guided injections per-
formed through different approaches such as medial patellar
or out-plane techniques without direct visualization of the
needle tip.9,21
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A
are alternative approaches using a posteromedial access and
an anterior access to the knee joint, mimicking anterior por-
tals used for knee arthroscopy, also with 100% accuracy and
without complications.24

FIGURE 6. A 52-year-old woman—arthro-CT images in sagittal (A) and axial (B) planes demonstrate postprocedure contrast-filled
articular recess (asterisks). Little contrast accumulation in the prefemoral fat pad is observed (arrows). The needle was pulled and
repositioned without another puncture, and adequate distention of the joint cavity by the contrast medium was achieved.

142 www.ultrasound-quarterly.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Ultrasound Quarterly • Volume 33, Number 2, June 2017
As far as we know, our study is the first to describe and eval-
uate the in vivo accuracy of knee ultrasound-guided in-plane in-
jection using a lateral suprapatellar approach under 30 to 45
degrees of flexion to administer articular contrast solution.
A semiflexion of 30 to 45 degrees was demonstrated to be
useful because it promotes a larger amount of fluid accumu-
lated in the suprapatellar recess without requiring quadriceps
contraction or auxiliary maneuvers. Moreover, the performed
technique allowed for direct visualization and real-time filling
of the cavity, assuring all contrast solution to be adequately
injected. Furthermore, such technique permits to control the
needle throughout the entire procedure from the puncture site
to the articular cavity, avoiding vital structures such as tendons
and cartilage.
In our study, such a technique showed 100% accuracy in
reaching adequate articular filling of the contrast solution. Only
in 5 cases (5.8%) did we need to pull the needle back for repo-
sitioning without requiring a new puncture. Such results are
very similar to previous studies using similar techniques for
steroid injections.3,8,10,14–16 We did not find any local compli-
cations either using imaging examinations and after reviewing
clinical and arthroscopic surgical reports. Considering cost-
effectiveness, safety, absence of radiation, and comfort provided
to patients, the technique presented is an excellent alternative
to existing techniques, either blinded or imaging guided.
The current study presents limitations that need to be con-
sidered. It is a retrospective study, which did not permit us to
'S
control all variables related to the procedure itself or clinical
and surgical postprocedural evaluation. A strength of this study
is that all injections were performed by 1 radiologist using the
same technique; however, that fact precludes procedure repro-
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ducibility analysis. The lack of a control group is also a limita-
tion. Therefore, prospective studies using different techniques
and with adequate group comparisons are encouraged. Besides
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these factors, we believe our results are novel to represent a clin-
ical application of this technique in the clinical setting.
Our study demonstrates that in plane ultrasound-guided
TH
injection of the knee in semiflexion approaching the lateral
suprapatellar recess is a safe and useful technique to administer
intra-articular contrast solution as an alternative method without
radiation exposure.
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REFERENCES
1. Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into
the intra-articular space of the knee. J Bone Joint Surg Am. 2002;84(9):
A
1522–1527.
2. Otjen J, Parnell SE, Menashe S, et al. Ultrasound-guided joint injections
for MR arthrography in pediatric patients: how we do it. Pediatr Radiol.
2015;45(3):308–316.
3. Block JE, Berkoff DJ, Miller LE. Clinical utility of ultrasound guidance for
intra-articular knee injections: a review. Clin Interv Aging. 2012;7:89–95.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
View publication stats Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Lateral Suprapatellar Approach for Knee Injection
4. Dépelteau H, Bureau NJ, Cardinal E, et al. Arthrography of the shoulder:
a simple fluoroscopically guided approach for targeting the rotator cuff
interval. AJR Am J Roentgenol. 2004;182(2):329–332.
5. Perdikakis E, Drakonaki E, Maris T, et al. MR arthrography of the
shoulder: tolerance evaluation of four different injection techniques.
Skeletal Radiol. 2013;42(1):99–105.
6. Ng AW, Hung EH, Griffith JF, et al. Comparison of ultrasound versus
fluoroscopic guided rotator cuff interval approach for MR arthrography.
Clin Imaging. 2013;37(3):548–553.
7. Esenyel C, Demirhan M, Esenyel M, et al. Comparison of four different
intra-articular injection sites in the knee: a cadaver study. Knee Surg Sports
Traumatol Arthrosc. 2007;15(5):573–577.
8. Curtiss HM, Finnoff JT, Peck E, et al. Accuracy of ultrasound-guided and
palpation-guided knee injections by an experienced and less-experienced
injector using a superolateral approach: a cadaveric study. PM&R.
PY
2011;3(6):507–515.
9. Park Y, Lee SC, Nam HS, et al. Comparison of sonographically guided
intra-articular injections at 3 different sites of the knee. J Ultrasound Med.
2011;30(12):1669–1676.
10. Hermans J, Bierma-Zeinstra SM, Bos PK, et al. The most accurate approach
for intra-articular needle placement in the knee joint: a systematic review.
Semin Arthritis Rheum. 2011;41(2):106–115.
11. Souza PM, Aguiar RO, Marchiori E, et al. Arthrography of the shoulder:
O
a modified ultrasound guided technique of joint injection at the rotator
interval. Eur J Radiol. 2010;74(3):e29–e32.
12. Zwar RB, Read JW, Noakes JB. Sonographically guided glenohumeral
joint injection. AJR Am J Roentgenol. 2004;183(1):48–50.
C
13. Rutten MJ, Collins JM, Maresch BJ, et al. Glenohumeral joint injection:
a comparative study of ultrasound and fluoroscopically guided techniques
before MR arthrography. Eur Radiol. 2009;19(3):722–730.
14. Im SH, Lee SC, Park YB, et al. Feasibility of sonography for intra-articular
injections in the knee through a medial patellar portal. J Ultrasound Med.
2009;28(11):1465–1470.
15. Bum Park Y, Ah Choi W, Kim YK, et al. Accuracy of blind versus
ultrasound-guided suprapatellar bursal injection. J Clin Ultrasound.
2012;40(1):20–25.
16. Sibbitt WL, Band PA, Kettwich LG, et al. A randomized controlled trial
evaluating the cost-effectiveness of sonographic guidance for intra-articular
injection of the osteoarthritic knee. J Clin Rheumatol. 2011;17(8):409–415.
17. Sibbitt WL, Kettwich LG, Band PA, et al. Does ultrasound guidance
improve the outcomes of arthrocentesis and corticosteroid injection of the
knee? Scand J Rheumatol. 2012;41(1):66–72.
18. Hurdle M-FB, Wisniewski SJ, Pingree MJ. Ultrasound-guided
intra-articular knee injection in an obese patient. Am J Phys Med Rehabil.
2012;91(3):275–276.
19. Hirsch G, O'Neill T, Kitas G, et al. Distribution of effusion in knee arthritis
as measured by high-resolution ultrasound. Clin Rheumatol. 2012;31(8):
1243–1246.
20. Schweitzer ME, Falk A, Berthoty D, et al. Knee effusion: normal distribution
of fluid. AJR Am J Roentgenol. 1992;159(2):361–363.
21. Jang SH, Lee SC, Lee JH, et al. Comparison of ultrasound (US)-guided
intra-articular injections by in-plain and out-of-plain on medial portal
of the knee. Rheumatol Int. 2013;33(8):1951–1959.
22. Ike RW, Somers EC, Arnold EL, et al. Ultrasound of the knee during
voluntary quadriceps contraction: a technique for detecting otherwise
occult effusions. Arthritis Care Res (Hoboken). 2010;62(5):725–729.
23. Park KD, Ahn JK, Lee SC, et al. Comparison of ultrasound-guided
intra-articular injections by long axis in plane approach on three different
sites of the knee. Am J Phys Med Rehabil. 2013;92(11):990–998.
24. Tresley J, Jose J. Sonographically guided posteromedial approach for
intra-articular knee injections: a safe, accurate, and efficient method.
J Ultrasound Med. 2015;34(4):721–726.
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