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Aspiration and Injection of Joints and Soft Tissue Joseph J. Ruane, DO Medical Director, Musculoskeletal Health McConnell Heart Health Center Team Physician Columbus Blue Jackets Goals Key anatomy and landmarks Practical review of techniques and pitfalls – Shoulder – Knee, including viscosupplementation – Lateral epicondyle – Soft tissue injection Intra-articular Corticosteroids - Indications Rheumatoid arthritis Gout Pseudogout Systemic lupus erythematosus and mixed connective tissue disease Acute traumatic arthritis Osteoarthritis Inflammatory bowel disease with peripheral joint involvement Shoulder periarthritis (adhesive capsulitis, or frozen shoulder) Conditions with peripheral joint manifestations (ankylosing spondylitis, psoriatic arthritis, and Reiter's disease) Tietze's syndrome Intra-articular Corticosteroids Contraindications Absolute Contraindications: Overlying cellulitis or infected joint/bursa Severe overlying dermatitis Bacteremia Allergy to any of the medications Prosthetic joints Relative Contraindications: Coagulation disorder Uncooperative patient Significant Obesity Uncontrolled diabetes Corticosteroids for Joint Injection Drug Hydrocortisone acetate (Hydrocortone Acetate) 25 mg/mL 50 mg/mL Shoulder Knee Ankle Elbow Wrist 4-8 mL 1-2 mL 2-3 mL 1.0-1.5 mL 1-2 mL 0.5-1.0 mL 0.5-1.0 mL 0.25-0.5 mL 1 mL 0.5 mL Triamcinolone acetonide (Kenalog-40) 40 mg/mL 1 mL 1 mL 1 mL 1 mL 1 mL Triamcinolone diacetate (Aristocort) 25 mg/mL (Intralesional) 1-2 mL 1-2 mL 1-2 mL 0.5-1.0 mL 0.5-1.0 mL 40 mg/mL (Forte Parenteral) 0.5-1.0 mL 0.5-1.0 mL 0.5-1.0 mL 0.25-0.5 mL 0.25-0.5 mL Triamcinolone hexacetonide (Intra-articular Aristospan) 20 mg/mL 0.5-1.0 mL 0.5-1.0 mL 0.5-1.0 mL 0.5 mL 0.5 mL Methylprednisolone acetate (Depo-Medrol 20 mg/mL 40 mg/mL 80 mg/mL 1.0-4.0 mL 0.5-2.0 mL 0.25-1.0 mL 1.0-4.0 mL 0.5-2.0 mL 0.25-1.0 mL 1.0-4.0 mL 0.5-2.0 mL 0.25-1.0 mL 0.5-2.0 mL 0.25-1.0 mL 0.1-0.5 mL 0.5-2.0 mL 0.25-1.0 mL 0.1-0.5 ml Onset, Duration, and Toxicity of Local Anesthetics Drug Onset Duration Max volume Lidocaine HCl 1% 2% 1-2 min 1-2 min ~1 hr ~1 hr 20 mL 10 mL 8 hr 8 hr 60 mL 30 mL Bupivacaine HCl 0.25% 30 min 0.5% 30 min Injection Technique If aspiration is not necessary, local anesthesia at the injection site may be omitted A 22 or 25-gauge needle that is 1.25 to 1.5 inches long is appropriate A 16- or 18-gauge needle is required to aspirate thick joint fluid or purulent exudate Vapo-coolant spray (or similar) may be used prior to injection to decrease entry pain. Spray for 3-5 seconds and wait for fluid to evaporate before injecting Injection Technique CARDINAL RULES ALWAYS – AWAYS ASPIRATE NEVER – NEVER – INJECT AGAINST RESISTENCE ALWAYS – ALWAYS – KNOW YOUR ANATOMY NEVER – NEVER – FORGET TO DISCUSS SIDE EFFECTS Intra-articular Corticosteroids: Possible Sequela Tissue atrophy Fat necrosis Erythematous flushing of skin (chest and face) Skin depigmentation Uterine bleeding Tendon rupture (<1%) Calcification (up to 40%) Post-injection flare of symptoms (2-5%) Nerve damage Charcot-like arthropathy ("steroid arthropathy”) Posterior subcapsular cataracts Pancreatitis (rare) Cushing's (rare) Fluid retention Osteonecrosis (rare) latrogenic infection (rare) Arthrocentesis and Injection of the Knee Anatomy and Landmarks JBJS Accuracy of Needle Placement Accuracy of Needle Placement Into the Intra-Articular Space of the Knee Jackson, D.W. et al.; Journal of Bone and Joint Surgery. Vol 84-A, NO.9. Sept 2002, 1552 Anatomy and Landmarks Anatomy and Landmarks Anatomy and Landmarks Surface Anatomy - Seated Surface Anatomy – Supine Lateral Arthrocentesis and Injection of the Knee Technique and Pitfalls Injection Technique Injection Technique Aspiration of Effusion Effusion: Color-Enhanced MRI Aspiration of Effusion Anatomic Pitfalls “Corticosteroid Injections Safe for Knee Osteoarthritis” 68 patients with knee OA 34 patients each received triamcinolone acetonide or saline, every 3 months for 2 years Neither group showed disease progression; changes in the mean joint-space width were not significant Ralnauld Je Buckland-Wright C, Ward R, et al, Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial; Arthritis Rheum. 2003;48:370-377 “Corticosteroid Injections Safe for Knee Osteoarthritis” 68 patients with knee OA 34 patients each received triamcinolone acetonide or saline, every 3 months for 2 years Neither group showed disease progression; changes in the mean joint-space width were not significant Ralnauld Je Buckland-Wright C, Ward R, et al, Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial; Arthritis Rheum. 2003;48:370-377 Viscosupplementation Proposed Modes of Action: Restoration of viscoelastic properties “Normalization” of HA synthesis by synoviocytes Anti-inflammatory effects Analgesic effects Synovial Fluid Elastoviscosity Dynamic Moduli at 2.5 Hz Normal (18- to 27-year-olds) Osteoarthritic Elasticity (Pa) Viscosity (Pa) 117 ± 13 45 ± 8 8±5 5±3 Reference: Balazs EA. The physical properties of synovial fluid and the special role of hyaluronic acid. In: Helfet AJ. Disorders of the Knee. 2nd ed. Philadelphia, PA: JB Lippincott Company; 1982:61-74. Confirmation of Joint Entry Aspiration of joint fluid Withdrawal of air bubbles Contact with the articular cartilage Water vapor in nozzle Air injection If You Are NOT in the Joint Pain with initial fluid bolus Resistance to injection Visible expansion of soft tissue Discomfort with leg extension or ambulation post injection Injection of the Shoulder Anatomy and Landmarks Anatomy and Landmarks Anatomy and Landmarks Anatomy and Landmarks Anatomy and Landmarks Subacromial Bursa Surface Anatomy Surface Anatomy Injection of the Shoulder Technique and Pitfalls Subacromial Injection Sub-Acromial Injection No more than three injections in 12 weeks M.E. BRUNET, MD et al; Patient Care; Jan 15 1997 Soft Tissue Injections Injection of the Lateral Epicondyle Anatomy and Landmarks Anatomy and Landmarks Anatomy and Landmarks Anatomy and Landmarks Injection and Pitfalls Pes Ancerine Bursa Trochanteric Bursa Plantar Fascia Coding 101.5 PROCEDURES 20600 0101 Arthrocentesis Small Joint 20605 0110 Arthrocentesis Med Joint 20610 0200 Arthrocentesis Major Joint 20550 0233 Ligament/Trigger/Cyst 20551 0153 Tendon origin/insertion 20552 0153 Trigger pt(s) 1-2 muscle gps 20553 0153 Trigger pt(s) 3+ muscle gps 90782 09.00 I.M Injection Coding 101.5 MODIFIERS .25 Visit plus procedure .50 Bilateral injection .59 Multiple injections. procedures INJECTABLES UNITs J1100 Dexameth (1ml = 1 unit) J3301 Kenalog (1ml = 1 unit) J1885 Toradol (1ml = 1 unit) J7320 Synvisc (2ml = 1 unit) Summary Satisfying procedures for both patient and physician Generally safe and effective – but remember the cardinal rules Thank You Thank You !