Aspiration and Injection of Joints and Soft Tissue

1. Aspiration and Injection ofJoints and Soft Tissue Joseph J. Ruane, DO Medical Director, Musculoskeletal Health McConnell Heart Health Center Team Physician Columbus Blue Jackets

2. Goals • Key anatomy and landmarks • Practical review of techniques and pitfalls • Shoulder • Knee, including viscosupplementation • Lateral epicondyle • Soft tissue injection

3. 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 - Indications

4. Intra-articular CorticosteroidsContraindications 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

5. Corticosteroids for Joint Injection

6. Onset, Duration, and Toxicity of Local Anesthetics DrugOnsetDurationMax volume Lidocaine HCl 1% 1-2 min ~1 hr 20 mL 2% 1-2 min ~1 hr 10 mL Bupivacaine HCl 0.25% 30 min 8 hr 60 mL 0.5% 30 min 8 hr 30 mL

7. 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

8. Injection Technique CARDINAL RULES ALWAYS – AWAYS ASPIRATE NEVER – NEVER – INJECT AGAINST RESISTENCE ALWAYS – ALWAYS – KNOW YOUR ANATOMY NEVER – NEVER – FORGET TO DISCUSS SIDE EFFECTS

9. Intra-articular Corticosteroids:Possible Sequela • Tendon rupture (<1%) • Calcification (up to 40%) • Post-injection flare of symptoms (2-5%) • Tissue atrophy • Fat necrosis • Erythematous flushing of skin (chest and face) • Skin depigmentation • Uterine bleeding • Nerve damage • Charcot-like arthropathy ("steroid arthropathy”) • Posterior subcapsular cataracts • Pancreatitis (rare) • Cushing's (rare) • Fluid retention • Osteonecrosis (rare) • latrogenic infection (rare)

10. Arthrocentesis and Injection of theKnee Anatomy and Landmarks

11. JBJS

12. 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

13. Anatomy and Landmarks

14. Anatomy and Landmarks

15. Anatomy and Landmarks

16. Surface Anatomy - Seated

17. Surface Anatomy – Supine Lateral

18. Arthrocentesis and Injection of theKnee Technique and Pitfalls

19. Injection Technique

20. Injection Technique

21. Aspiration of Effusion

22. Effusion: Color-Enhanced MRI

23. Aspiration of Effusion

24. Anatomic Pitfalls

25. “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

26. “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

27. Viscosupplementation Proposed Modes of Action: • Restoration of viscoelastic properties • “Normalization” of HA synthesis by synoviocytes • Anti-inflammatory effects • Analgesic effects

28. Synovial Fluid Elastoviscosity Dynamic Moduli at 2.5 Hz 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.

29. Confirmation of Joint Entry • Aspiration of joint fluid • Withdrawal of air bubbles • Contact with the articular cartilage • Water vapor in nozzle • Air injection

30. 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

31. Injection of the Shoulder Anatomy and Landmarks

32. Anatomy and Landmarks

33. Anatomy and Landmarks

34. Anatomy and Landmarks

35. Anatomy and Landmarks

36. Subacromial Bursa

37. Surface Anatomy

38. Surface Anatomy

39. Injectionof the Shoulder Technique and Pitfalls

40. Subacromial Injection

41. Sub-Acromial Injection No more than three injections in 12 weeks M.E. BRUNET, MD et al; Patient Care; Jan 15 1997

42. Soft Tissue Injections

43. Injection of the Lateral Epicondyle

44. Anatomy and Landmarks

45. Anatomy and Landmarks

46. Anatomy and Landmarks

47. Anatomy and Landmarks

48. Injection and Pitfalls

49. Pes Ancerine Bursa

50. Trochanteric Bursa