Download Lower Extremity Workshop

Lower Extremity Workshop
Gil C. Grimes, MD
February 22nd 2007
Objectives
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Indications for aspiration and injections
Contraindications to aspiration
Contraindications to injection
Medications
Tests to consider
Adverse reactions and complications
Techniques
Indications for Arthrocentesis
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Crystal-induced arthropathy
Hemarthrosis
Limiting joint damage from an
infectious process
Symptomatic relief of a large effusion
Unexplained joint effusion
Unexplained monarthritis
Contraindications for
Aspiration
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Bacteremia
Clinician unfamiliar with anatomy of or
approach to the joint
Inaccessible joints
Joint prosthesis
Overlying infection in the soft tissues
Severe coagulopathy
Severe overlying dermatitis
Uncooperative patient
Contraindications for
Injections
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Adjacent osteomyelitis
Bacteremia
Hemarthrosis
Impending (scheduled within days) joint
replacement surgery
Infectious arthritis
Contraindications for
Injections
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Joint prosthesis
Osteochondral fracture
Periarticular cellulitis
Poorly controlled diabetes mellitus
Uncontrolled bleeding disorder or
coagulopathy
Failure to improve with prior injections
Medications
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Considerations
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Duration of effect (related to solubility)
Potency of steroid
Mineralocorticoid effects
Hydrocortisone acetate (Hydrocortone)
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Low potency
Short
10 to 25 mg for soft tissue and small joints
50 mg for large joints
Medications
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Methylprednisolone acetate (DepoMedrol) or triamcinolone acetonide
(Aristocort)
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Intermediate potency
Intermediate duration
2 to 10 mg for soft tissue and small joints
10 to 80 mg for large joints
Medications
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Betamethasone sodium phosphate and
acetate (Celestone Soluspan)
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High potency
Long duration
1 to 3 mg for soft tissue and small joints
2 to 6 mg for large joints
Medications
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Dexamethasone sodium phosphate
(Decadron)
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High potency
Long duration
0.5 to 3 mg for soft tissue and small joints
2 to 4 mg for large joints
Steroid Agents
Agent
Relative antiinflammatory
potency
Relative
mineralocorticoid
potency
Solubility
Hydrocortisone acetate
1
2-3
High
Prednisolone tebutate
4
1
Medium
Methylprednisolone acetate
5
0
Medium
Triamcinolone acetonide
5
Triamcinolone diacetate
Triamcinolone hexacetonide
0
Medium
Betamethasone sodium
phosphate and acetate
20-30
0
Low
Dexamethasone acetate and
sodium phosphate
20-30
0
Low
Anesthetic Agents
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Use higher concentration smaller
volume for small joints
Drug Onset of action Duration of action Maximum volume
Lidocaine HCl
1%
1-2 min
~1 hr
20 mL
2%
1-2 min
~1 hr
10 mL
0.25% 30 min
8 hr
60 mL
0.5%
8 hr
30 mL
Bupivacaine HCl
30 min
Hyaluronic Derivatives
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Hylan G-F 20 (Synvisc)
Systematic review suggests efficacy
Cochrane review of 76 trials
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40 vs placebo
6 vs NSAIDs
10 vs steroids
Median quality
About as good as steroids
Cochrane Library 2006 Issue 2:CD005328
Hyaluronic Costs
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Euflexxa 20 mg/2 mL $139.20, repeated weekly for 3
weeks
Hyalgan 20 mg/2 mL $138.94, repeated weekly for 35 weeks, also available in 2 mL vials
Orthovisc 30 mg/2 mL $123.90, repeated weekly for
3-4 weeks
Synvisc 16 mg/2 mL $233.08, repeated weekly for 3
weeks
Supartz 25 mg/2.5 mL $120.70, repeated weekly for
3-5 weeks
Steroid Costs
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Methylprednisolone acetate 20-80 mg
as generic $1.40, Depo-Medrol $1.61
Triamcinolone acetonide (Kenalog) 2080 mg $1.39
Triamcinolone diacetate (Aristocort
Forte) 20-80 mg $1.44
Triamcinolone hexacetonide (Aristospan
Intra-articular) 20-80 mg $1.26
The Medical Letter 2006 Mar 27;48(1231):25
Tests to Consider
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If there is warmth, painful effusion, marked
pain with range of motion, exquisite
tenderness consider infections
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Blood work- ESR, glucose, protein
Joint Fluid
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Cell count and differential
Glucose and protein
Cultures
Gram stain
Crystal analysis
Complications
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Caused by injection
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Bleeding (rare)
Infection (1 in 10,000)
Joint injury (incidence unknown): Avoid by
aspirating slowly and not moving needle
side to side in joint
Complications
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Caused by corticosteroid agent
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Acceleration of septic joint
Subcutaneous fat atrophy (<1%), particularly if
injection is <5 mm beneath skin surface
Fistulous tract formation
Steroid flare with pain 6 to 12 hr after injection
(2% to 5%)
Exacerbation of diabetes (rare)
Osteoporosis (high doses over long period)
Cartilage damage, particularly in weight-bearing
joints
Complications
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Caused by corticosteroid agents
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Tendon rupture (<1%)
Facial flushing (<1%)
Transient paresis of injected extremity (rare)
Asymptomatic pericapsular calcification (43%)
Adverse gastrointestinal effects
Mood alterations
Fluid retention
Menstrual irregularities
Allergic or hypersensitivity reactions
Techniques Knee
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Lateral mid patella
approach preferred
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Most likely to hit the
joint
Study of 80 patients
injected 3 separate
times by same
physician
Knee Extended
J Bone Joint Surg Am 2002 Sep;84-A(9):1522
Techniques Knee
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Need the following
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Large syringe for
aspiration
Second syringe with
medications
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Up to 10 ml total
volume
22 gauge needle 1.5
inches long
Alcohol wipes
Betadine wipes
Bandage
Techniques Ankle Foot
Techniques Ankle I
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Medication total volume should not
exceed about 7 ml
Palpate the junction of the fibula and
the tibia just superior to the talus
Palpate this soft triangular space
Advance needle into space
If bone encountered redirect medial
and superiorly
Techniques Ankle II
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The space between anterior border of
the medial malleolus
The medial border of the tibialis
anterior tendon
Palpates this space for the articulation
of the talus and tibia.
Direct the needle postero-laterally
Techniques Ankle Foot
Techniques Tarsal Tunnel
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Caused by compression of posterior
tibial nerve
Tunnel is formed by medial malleolus
and fibrous flexor retinaculum
Chief complaint is burning sensation
over the medial 1/3 of the foot
Look for Tinel’s sign
Techniques Tarsal Tunnel
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Medication volume should not exceed 3
ml
Needle is inserted 2 cm proximal to the
identified location
Angle is 30 degrees to the foot
Tunnel is very superficial
Aspirate prior to injection to make sure
not in a vessel
Techniques Tarsal Tunnel
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Patient in lateral position with affected
foot on bed
Find positive Tinel’s sign
Identify the posterior tibial tendon
Patient inverts foot against resistant
Nerve lies behind the tendon
Techniques Ankle Foot
Techniques 1st MTP Joint
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Total volume should not exceed 2 ml
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Roughly 1 ml Lidocaine
Roughly 0.25-0.5 ml Celestone
May be difficult to palpate this joint
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Distraction helps open the joint
Insert from medial approach
Angle 60-70 degrees to conform to joint
angles
General References
Zuber TJ. Knee join aspiration and injection.
American Family Physician 2002 Oct
15;66(8):1497-500, 1503-4, 1507
Rifat SF, Moeller JL. Basics of joint injection:
general techniques and tips for safe, effective
use. Postgraduate Medicine 2001;109(1):157166
Rifat SF, Moeller JL. Site-specific techniques of
joint injection: useful additions to your
treatment repertoire. Postgraduate Medicine
2001;109(3):123-36