Arthrocentesis and Joint Injection for the Internist

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Arthrocentesis and Joint Injection for the
Internist

• Suzanne Emil, MDRheumatology Fellow
• University of New Mexico

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Overview

• Indications for Aspiration or Injection
• Choice of Glucocorticoid Preparation
• Frequency of Injections
• Techniques
• Knee
• Shoulder
• Ankle
• Wrist

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Indications for Aspiration

• Evaluation of any unknown joint effusion
• Evaluation for septic arthritis
• Initial confirmation of gouty arthritis
• Aspiration to reduce the size of an effusion
  prior to injection of glucocorticoid
• Improved outcome for patients with RA

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Indications for Injection

• Rheumatoid Arthritis, persistent activity in
  large or medium sized joints
• May slow erosion
• Other inflammatory arthritides, erosive or not.
  Particularly helpful if oligoarticular
• Osteoarthritis of large weight bearing joint with
  bone on bone pain
• Small joint osteoarthritis (CMC)
• Subdeltoid bursitis or rotator cuff tendonitis

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Relative Contraindications

• Rheumatoid arthritis in small joints of the hand
• Rheumatoid arthritis with one joint out of
  proportion to othersuntil infection ruled out
• Monoarthritis with septic appearing joint,
  especially in diabetics
• Early OA (cartilage repair may be important)
• Small joint OA which failed to respond for 6
  weeks to a prior injection
• Subacute shoulder pain not responsive to a prior
  injection

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Choice of Glucocorticoid Preparation

• Generally prefer Triamcinolone for
  intra-articular (IA) injections (causes potent
  soft-tissue atrophy)
• IA injection atrophies the pathologic synovial
  membrane (desired)
• Extra-Articular injection atrophies fat, muscle,
  skin and ruptures tendons (undesired)
• Generally prefer Methylprednisolone for
  tendon/bursa injections (less soft-tissue atrophy
  and complications, but less effective for joints)

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Frequency of Injection

• Typically limit to a maximum of 4 injections/year
  for any given joint
• For OA with inevitable joint replacement, can
  perform palliative injections once every 3 months
• But not within 4 months of a TJA (increased
  infection rate)

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Complications

• Infection, approximately 1/3500 procedures (at
  UNM less than 1/15,000 procedures)
• Post-Injection Flare
• lt48hours, but may last up to 72 hours
• Flushing-Anxiety, Sleeplessness Reaction
• 10 of patients receiving triamcinolone acetonide
  
• Leakage of joint fluid
• More common with drainage of popliteal cyst,
  incomplete drainage, anticoagulants, and drainage
  of effusion using gt22g needle, also common in
  infected (septic) joint (fistula formation)
• Steroid atrophy (subcutaneous fat, skin, muscles,
  tendons)
• Skin hypopigmentation
• Tendon rupture
• RA, biceps tendon, rotator cuff injections (more
  common with posterior injections), achilles
  tendon
• Prior use of fluoroquinolones

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Complications
Skin Hyperpigmentation
Steroid Skin Atrophy
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General Considerations

• 1 step technique
• 1 needle, syringe (lidocaine and corticosteroid
  are mixed)After antisepsis, with appropriate
  needle, quick, sure puncture through skin and
  joint capsule precludes need for local skin
  anesthesia
• Benefits
• 1 stick
• Disadvantages
• Preservatives in lidocaine may decrease
  sensitivity of synovial fluid culture if
  lidocaine contaminates a SMALL culture sample
• More painful if readjustment of needle required
  (frequent)
• Patients do not like one-step injections and they
  are less effective

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General Considerations

• 2 step technique
• 1 needle, 2 syringes (1 lidocaine syringe, 1
  corticosteroid syringe, no mixing)Change syringe
  between anesthesia-aspiration and injection
• 93 of patients prefer the use of lidocaine
  anesthesia vs. 1-step
• Lidocaine creates a low pressure pocket at
  needle tiphydrodissects and dilates joint space
• Low pressure prevents reflux of corticosteroid
  back along needle track that causes atrophy,
  maintains more corticosteroid in target, and
  allows for anesthesia without causing atrophy
  from steroid administration before joint space is
  reached
• Allows complete aspiration and evaluation of
  fluid before injecting steroid (complete
  decompression and aspiration of joint fluid
  before injection improves response and duration
  by 20 to 30)

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Knee

• 21 gauge or 22 gauge, 2-inch needle
• 80mg Triamcinolone Acetate
• 3-4cc 1 Lidocaine
• For aspiration, easiest if patient supine with
  knee almost fully extended (10 degrees)
• Just posterior to lateral aspect of the patella
  in the recess behind the patella where a bulge
  can be detected on exam
• Direct posterior and slightly inferiorly

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Hazardous Anatomy of the Lateral Knee

• Superiorly Superior Geniculate Artery
• Medially Inferior Geniculate Artery
• Inferiorly Anterior Recurrent Tibial Artery

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Knee Arthrocentesis
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Preferred Lateral Knee Approach for
ArthrocentesisSuprapatellar Bursa or Lateral
Proximal Patellar
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Knee ArthrocentesisLateral Suprapateller Bursa
With the patient supine, a mark is made in the
recess (or where there is a fluid bulge) behind
the lateral portion of the patella (black), at
the proximal edge of the patella. The needle
should be advanced 1.5 inches or more until fluid
is obtained
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Knee ArtrhocentesisLateral Midpatellar
With the patient supine, the needle is introduced
under the patella from lateral to medial, and
corticosteroid is injected in the patellofemoral
joint (Jackson technique). This is 93 accurate,
but not as successful for arthrocentesis.
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Anteriolateral Inferiopatellar Bent Knee
Approach to Injection
Anterolateral portal is defined by the adjoining
structures of the inferolateral border of the
patella, the patellar tendon, and the lateral
tibial plateau. Needle direction is under the
patellar tendon, though the anterior fat pad
until bevel engages the medial femoral condyle
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Anteriolateral Inferiopatellar Bent Knee
Approach to Injection
Lateral Femur
Patella
Target
Patellar Tendon
Tibial Plateau
Medial
Lateral
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Bent Knee
Anterolateral portal is defined by the adjoining
structures of the inferolateral border of the
patella, the patellar tendon, and the lateral
tibial plateau. Needle direction is under the
patellar tendon, though the anterior fat pad
until bevel engages the medial femoral condyle
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Shoulder

• 21 gague or 22 gague, 1 ½ or 2-inch needle
• 60mg Triamcinolone Acetate
• 2-3mg 1 Lidocaine
• Patient sitting, shoulder in neutral position
• Needle insertion site is 2 cm inferiorly and 1 cm
  lateral to the choracoid process
• Needle direction is posterior and lateral,
  keeping needle flat (parallel to ground)

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Hazardous Anatomy of the Posterior Shoulder

• Superior-Medial Suprascapular Artery
• Medial-Inferior Posterior Circumflex Humeral
  Artery

Posterior Subscapular Approach
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Preferred Anterior Shoulder ApproachLateral to
Coracoid Process
Target
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Shoulder Arthrocentesis
Anterior approach The needle is inserted at a
point just medial to the head of the humerus,
slightly inferior and lateral to the coracoid
process (marked in black), which is just inferior
to the lateral aspect of the clavicle (marked in
black above)
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Ankle

• 22 gauge, 1 ½-inch needle
• 60mg Triamcinolone
• 2-3mg 1 Lidocaine
• Leg-foot angle at 90 degrees
• Needle insertion site is just medial to tibialis
  anterior tendon and lateral to the medial
  malleolus
• Direct needle posteriorly and perpendicular to
  the tibia shaft

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Hazardous Anatomy of the Ankle

• Distal - Dorsal Artery of Foot
• Proximal Anterior Tibial Artery
• Lateral Fibular Interosseus Artery

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Ankle
Anterior approach (tibiotalar joint) With the
ankle at a 90-degree angle to the lower leg, the
needle is inserted at a point just lateral to the
medial malleolus (black marking) and just medial
to the tibialis anterior tendon. The needle is
directed posteriorly, perpendicular to the shaft
of the tibia
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Preferred Ankle ApproachesLateral or Medial
Ankle
Medial Approach
Talus
Talus
Lateral Approach
Tibia
Tibia
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Preferred Ankle ApproachesLateral or Medial
Ankle
Tibia
Fibula
Fibula
D. Pedis Artery
D. Pedis Artery
Lateral Approach
Medial Approach
Tibia
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Wrist

• 22 gauge-25 gauge, 1 to 1 ½ -inch long
• 40mg Triamcinolone Acetate
• 1-2cc 1 Lidocaine
• Needle insertion site is just distal to radius
  and just ulnar to the anatomic snuffbox
• Direction is perpendicular to the skin
• Advance needle approximately 0.75cm until fluid
  obtained

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Hazardous Anatomy of the Wrist

• Distal - Dorsal Carpal Arch
• Radially Radial Artery
• Medial Anterior Interosseus Artery

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Preferred Wrist ApproachDirectly Distal (1 cm)
to Radial Tubercle
Radial Tubercle
Ulna
Radial Tubercle
Carpal bones
Ulnar Head
Target
Target
Carpal Bones
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Acknowledgements

• Dr. Wilmer Sibbitt for his teaching and
  assistance with this presentation

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References

• Kelleys Textbook of Rheumatology 2008, 20th
  Edition
• UNMH Rheumatology Department
• Netter, Frank H. Atlas of Human Anatomy
• Up to Date Joint Aspiration or Injection in
  Adults Technique and Indications