Joint Aspiration or Arthrocentesis Hands on workshop Out Patient Procedures Joint and Trigger point injections Charles Haddad MD Associate Professor University of Florida DISCLOSURES I do not have any disclosures ID: 605775
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Joint and Trigger point injectionsJoint Aspiration or ArthrocentesisHands on workshop
Out Patient ProceduresSlide2
Joint and Trigger point injectionsCharles Haddad M.D. Associate Professor University of FloridaSlide3
DISCLOSURESI do not have any disclosures.No financial interest in subject being discussedSlide4
OBJECTIVESUpon completion of this activity, participants should be able to:
Understand advantages & disadvantages of joint injections.
Discuss the indications and contraindications of joint injections.
Evaluate different approaches and medications used in joint injections.
Improve confidence level of giving joint injection and trigger point injections.Slide5
OverviewThe BasicsWho and what should be injectedWho and what should not be injected
Risks vs. Benefits
What you need
EPIC Documentation/ Charges
HANDS ON WORKSHOPSlide6
The BasicsASPIRATION (Arthrocentesis)- inserting a needle into a joint to remove synovial fluid, or blood.INJECTION is usually performed with corticosteroids and a local anesthetic.Slide7
The BasicsAspiration and injection of a joint is performed to relieve pressure, decrease inflammation and for diagnosis.Corticosteroids may be injected once it has been established that the inflammation is not secondary to infection.
Aspiration of the joint or bursa can obtain fluid for synovial fluid analysis.Slide8
The BasicsJoint fluid can be sent for:WBCs infection/inflammation
C & S infection
Gram Stain infection
Crystals
gout-negative birefringent
urate
crystals
pseudogout
- Calcium Phosphate Dehydrate
C
rystals (CPPD)
Slide9
Do steroid injections work?Very few studies support or refute the efficacy of common joint intervention in medical practiceSubstantial practice based experience support the effectiveness of joint/soft tissue injections
Corticosteroid injections should always be viewed as adjuvant therapy eg physical therapySlide10
What can be Injected/AspiratedClean injuries with effusions
Degenerative Joint Disease with synovitis
Trigger fingers
Trigger points
Hemarthrosis
Areas of tendonitis Slide11
What can be Injected/AspiratedKnees: OA, Gout, Patellar bursitis, Meniscus injuryElbows : Lateral epicondyle tendonitis, Olecranon Bursa
Shoulders : OA, Rotator cuff tendonitis, Frozen shoulder, Subchromial Bursitis
Wrists : Carpal tunnel, DeQuervain tenosynovitisSlide12
What can be injected/AspiratedFingers/Thumb especially with trigger fingerHip
: Trochanteric
Bursitis
Ganglion Cysts
Trigger Point injectionsSlide13
Who and What should NOT be injectedAny areas suspected to be infectedAcute Fractures
Prosthetic Joints
Impending Joint replacement (within a few days)Slide14
Who and What should NOT be injectedPatients with uncontrolled bleeding disorders or uncontrolled diabetes
Achilles
Tendon
Any
ropey
tendon
Not as successful in the hip joint except at the trochanteric bursa Slide15
More commonly seen Risks and ways to avoidFat necrosis : deeper injection avoid subcutaneous fat
Patches
of hypo pigmentation(especially with
dark skin) deeper injections help to avoid
Elevations
in blood sugar(transient from several to 21 days
) Monitor sugars more closely after injection, may need to adjust medsSlide16Slide17
Risks and ways to avoid Pain: can be improved with ethyl chloride or distraction techniquesInfection (< 0.01%) : using sterile/clean techniques
Bleeding : avoid vascular structure
Tendon rupture: do not inject into the tendon itselfSlide18
More Risks and ways to avoidLong term effects if done too frequently is the same as chronic use of corticosteroids(weight gain, osteoporosis, high sugars).
Vasovagal reaction (frequent ~10%): perform injections in supine position if possible
If local anesthetic is injected into the vessel it can cause a toxic reaction(heart arrhythmias):avoid intravenous injection/aspirateSlide19
More Risks and ways to avoidPost injection flair(increased pain for several days after the injection) : icing the area down after the injectionWhite
blood cell margination, transient increase in WBCsSlide20
BenefitsDecreases pain: improve mobility for physical therapyDecreases pressure: especially with aspiration
Decreases inflammation
Improves range of motion
Effects are seen quickly(usually within a few days)Slide21
Frequency(keep it simple)No more frequently than every 2-3 monthsNo more than 2-3 time a year
Some clinicians recommend a lifetime limit Slide22
What you needFor preparation and skin anesthesia Cleaning solution- usually povidone- iodine solution
A drape (sometimes)
Sterile gloves
Small syringe~ 1-3ML to anestitize the skin
18 gauge needle to draw the local anesthetic and 25-30 gauge needle to inject
1% Lidocaine without epinephrineSlide23
What you needFor Aspiration18 gauge 1 ½ inch needle
20 ml syringe for larger joints
5-10 ml syringe for smaller jointsSlide24
What you needFor Corticosteroid injections22 gauge 1 ½ inch needle
5-10 ml syringe
The Corticosteroid solution
1% Lidocaine without
epinephrine
Inject within a few minutes of mixing to
avoid crystallization
Slide25
How much to give (Keep it simple)Large Joints 40 mg TriamcinaloneSmall Joints 10-20 mg Triamcinalone
Large joints; knees, shoulders, etc. add 4cc of Lidocaine 1% without epi
Smaller joints e.g. wrist, elbows add 2ccs of Lidocaine
Fingers, hand add 1cc of LidocaineSlide26
Steroid
Common concentration (mg per mL)
Common equivalent dose* (mg)
Approximate duration of action (days)
Methylprednisolone acetate (Depo-Medrol)
40 or 80
40
8
Triamcinolone acetonide (Kenalog)
10 or 40
40
14
Triamcinolone hexacetonide (Aristospan)
20
40
21
Dexamethasone acetate (Decadron LA†)
8
8
8
Dexamethasone sodium (Decadron†, Solurex†)
4
8
6
STEROID DOSING AND EQUIVALENTS
NOTE:
Steroid agents listed in order of prevalence of use
.
Commonly Used SteroidsSlide27
Medication
Onset of action (minutes)
Duration of action (hours)
Max volume of injection*
0.25% Bupivacaine (Marcaine)
30
8
60 mL
0.5% Bupivacaine
30
8
30 mL
1% lidocaine (Xylocaine)
1 to 2
1
20 mL
2% lidocaine
1 to 2
1
10 mL
LOCAL ANESTHETICS OR JOINT INJECTION
*—
Increased risk of cardiac toxicity or arrhythmia above these dosages
.
Commonly Used Local Anesthetics Slide28
SynviscHylan G-F 20
An elastoviscous high molecular weight fluid containing hylan A and hylan B
Produced from chicken combs
Hyaluronan is a long chain polymerSlide29
SynviscHylan G-F 20
Indication: treatment of pain in osteoarthritis of the knee in patients who have failed to respond to conservative therapy
Contraindication: patients who are hypersensitive or allergic to
hyalurornan
patients who have joint or skin infections in the
injection site
Precautions
Patients allergic to egg products and avian proteins
Slide30
SynviscHylan G-F 20
Technique: 2 mL Synvisc is injected intr-articularly into the knee joint once a week for three weeks
Strict aseptic technique must be followed
18-22 gauge needle is used
Same needle can be used to drain joint and inject Synvisc
Effectiveness in other joints has not been establishedSlide31
SynviscHylan G-F 20
Adverse effects: most commonly knee pain, swelling, and joint effusion Slide32Slide33Slide34Slide35Slide36
QUESTIONS????Slide37
HANDS ON WORKSHOP