Transcript OA and Sports - Scioto County Medical Society

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
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Key anatomy and landmarks
Practical review of techniques and
pitfalls
– Shoulder
– Knee, including
viscosupplementation
– Lateral epicondyle
– Soft tissue injection
Intra-articular Corticosteroids - Indications
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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:
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Overlying cellulitis or infected joint/bursa
Severe overlying dermatitis
Bacteremia
Allergy to any of the medications
Prosthetic joints
Relative Contraindications:
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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
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If aspiration is not necessary, local anesthesia at the
injection site may be omitted
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A 22 or 25-gauge needle that is 1.25 to 1.5 inches long is
appropriate
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A 16- or 18-gauge needle is required to aspirate thick joint
fluid or purulent exudate
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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
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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%)
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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”
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68 patients with knee OA
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34 patients each received
triamcinolone acetonide or saline,
every 3 months for 2 years
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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”
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68 patients with knee OA
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34 patients each received
triamcinolone acetonide or
saline, every 3 months for 2
years
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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:
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Restoration of viscoelastic properties
“Normalization” of HA synthesis by
synoviocytes
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Anti-inflammatory effects
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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
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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
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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
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Satisfying procedures for
both patient and physician
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Generally safe and effective
– but remember the cardinal
rules
Thank You
Thank You !