1. “The Art of the Injection”
By Jon C. Brillhart PA-C
Daivd Lannik MD
Portsmouth Orthopedics, Inc

2. Joint Injection Challenge
The art of good injection therapy is to place the appropriate amount of the appropriate medication into the exact site of the affected tissue.

3. “in the right quantity”, “given in the right stop”,
“The right medicine”,
“in the right quantity”,
“given in the right stop”,
“at the right time”.
Quoted from David Lannik MD, 2005.

4. Rational for injections
Diagnostic
1.) Joint Aspiration (confirm nature fluid)
2.) Provide symptom relief of affected body part.
Therapeutic
1.) Increase mobility and decrease pain.

5. Indications for Diagnostic and Therapeutic Injections
Soft Tissue conditions
Bursitis
Tendonitis or tendinosis
Trigger points
Ganglion cysts
Neuromas
Entrapment syndromes
Fasciitis

6. Indications for Diagnostic and Therapeutic Injections
Joint Conditions
Effusion of unknown origin or suspected infection.
Crystalloid arthropathies
Synovitis
Inflammatory arthritis
Advanced osteoarthritis

7. Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections
Absolute contraindications
Local cellulitis
Septic arthritis
Acute fracture
Bacteremia
Joint prosthesis
Achilles or patella teninopathies
History of allergy or anaphylaxis to injectable constituents

8. Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections
Minimal relief after two previous injections
Underlying coagulopathy
Anticoagulation therapy
(avoid soft tissue injection)
Evidence of surrounding joint osteoporosis
Anatomically inaccessible joints
Uncontrolled diabetes mellitus

9. Top Six Injections Chronic subdeltoid bursitis Shoulder capsulitis
Knee osteoarthritis
Tennis elbow
Trapezio metacarpel joint OA
Plantar fasciitis

10. General guidelines Check patient’s allergies
Don’t forget “the patient” (discuss the procedure in patient friendly terms, side effects, what to expect, etc).
Obtain informed consent! (verbal vs written)
Place patient in comfortable position that allows easy access to area injected.
Take time to identify structure being injected by locating pertinent anatomical landmarks.
Be empathetic, and reassure patient.
Document, Document, Document!!!

11. Equipment Safety (oxygen, anaphylaxis kit, crash cart, msds)
Appropriate needles and syringes
Medication with “in date” expirations!

12. Skin preparation The skin should be prepared with
providone-iodine or similar antiseptic solution. (Alcohol)
The risk of infection with use of alcohol skin preparation alone is reportedly estimated at 1 in 10,000.

13. Corticosteroids
Synthetic analogues of the adrenal glucocorticocoid hormone “cortisol” (hydrocortisone) with is secreted by the innermost layer (zona reticularis) of the adrenal cortex.
*Suppress inflammation (RA, PA, Gout).
*Suppress inflammatory flares (OA/DJD).

14. Corticosteroid Agents by Relative Potencies, Duration, and Dose
Agent Potency Duration Dose/Site
Hydrocortisone acetate Low Short 10 to 25 mg for
(Hydrocortone) soft tissue and
small joints
50 mg large joints
Methylprednisolone Intermediate Intermediate 2 to 10 mg for
(Depo Medrol) soft tissue and
Triamcinolone small joints
(Aristocort) to 80 mg for
large joints
Dexamethasone sodium High Long 0.5 to 3 mg for
(Decadron) soft tissue and small
joints
2 to 4 mg large joints
Betametasone sodium High Long 1 to 3 mg for soft tissue
phosphate and acetate and small joints
(Celestone Soluspan) to 6 mg large joints

15. Recommended maximum dosages and volumes for joint injections
Site Dosage Volume
Shoulder 30 mg 10 ml
Elbow 20 mg 5 ml
Wrist, Thumb 10 mg 2 ml
Fingers 5 mg 1 ml
Hip 40 mg 5 ml
Knee 40 mg 10 ml
Ankle, foot 20 mg 5 ml
Toes 10 mg 1ml

16. Side-effects of steroid injection therapy
Systemic side-effects
Facial flushing
Menstrual irregularity
Impaired diabetic control
Emotional upset
Hypothalmic – pituitary axis suppression
Fall in ESR/CRP
Anaphylaxis
Local side-effects
Post injection flare of pain
Skin depigmentation
Subcutaneous atrophy
Bleeding / bruising
Steroid “chalk”
Soft-tissue calcification
Steroid arthropathy
Tendon rupture or atrophy
Joint / soft-tissue infection

17. Local Anesthetics Provide pain relief
May help to differentiate between local and referred pain.
Provide fluid volume to the injection
Help distribute corticosteroid in large joints
May be short or long acting

18. Rule of….
Use more concentrated solutions (ie 2%) of lidocaine hydrochloride for small joints that require small injection volumes. (MCPJ)
Conversely, use a less concentrated (ie 1%) lidocaine hydrochloride for large joints that need increased volume. (Knee)

19. Warning!!!
Never use epinephrine / lidocaine solution on ears, nose, fingers and toes!!!

20. Onset, Duration, and toxicity of local anesthetics
Drug Onset Duration Max Vol
Lidocaine
1% 1-2 Min ~ 1 Hour 20 ml
2% 1-2 Min ~ 1 Hour 10 ml
Bupivacaine
0.25% 30 Min 8 hours 60 ml
0.50% 30 Min 8 Hours 30 ml

21. “A Failure of the Supporting Structure of the Total Organ (Joint)”
CHANGES ASSOCIATED WITH OSTEOARTHRITIS
Joint injury or deformity1
Imbalance of biosynthesis and degradation in cartilage, synovial fluid, bone, muscle, ligaments1
Inflammation1
Chronic wear and age1
Softening and loss of articular cartilage1
Decrease in concentration and average molecular weight of hyaluronic acid in synovial fluid2
“A Failure of the Supporting Structure of the Total Organ (Joint)”
1. Brandt KD. In: Harrison’s Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill; 1994:
2. Balazs EA, Denlinger JL. J Rheumatol. 1993;20(suppl 39):3-9.

22. Hyaluronic Acid Used to treat OA of the knee
Act as viscoelastic supplements that replace the diseased synovial fluid of the osteoarthritic joint
Act as a shock absorber and lubricates the joint! (How to explain this to pt?).

23. Synovial Fluid
Highly influences intercellular matrices of joint soft tissues
Unique combination of elasticity and viscosity
Hyaluronan responsible for elastoviscous properties
Elastoviscosity critical for joint function
Elastoviscosity reduced in osteoarthritis
Slide 4
• The joint interior has four tissue elements—articular cartilage, synovial tissue, intra-articular ligaments, and synovial fluid.1
• Synovial fluid (SF) permeates the tissues of the joint and significantly influences the nature of the intercellular matrix around chondrocytes, nociceptors, and synovial cells. 1
• Synovial fluid exhibits marked elastoviscous properties due to its hyaluronan content.1 The properties of the hyaluronan allow SF to dissipate energy through viscous flow or to behave like an elastic body, depending on the force applied to the joint. 1
• The SF in the osteoarthritic joint is considerably different from that of the normal joint. Hyaluronan may be diluted and lower in molecular weight in osteoarthritis. Consequently, elasticity and viscosity are significantly lower.1
1. 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:

24. Viscosupplementation Basic Principle
100 90 10
Slide 10
• This slide is a graphical illustration of the elastic and viscous behavior of solutions of hyaluronan or hylans. As the frequency of deforming force varies, elastic behavior is increased in relation to viscous behavior. In general, as the frequency or quickness of applied deformation force increases, the more elasticity these solutions exhibit. At a point during normal activities, the behavior of normal synovial fluid crosses over from predominantly viscous to predominantly elastic behavior. SF in the joint of OA patients is generally less elastic than normal SF to the same force. The crossover from viscous to elastic behavior occurs later if at all in osteoarthritic synovial fluid. A purified hyaluronan product with chains of low molecular weight (500,000) shows very little elasticity. Hylan G-F 20, on the other hand, behaves predominantly elastically throughout the range of forces seen with normal movements.1
1. 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; 1983: 80 20
hylan G-F 20MW 6 million 70 30 60
Normal 40
% Elasticity
% Viscosity 50 OA 50 40 60 30 70
running 20 80
walking
jumping 10 90
HA MW
500,000
100
0.01
0.1 1 10 20
Frequency (Hz)

25. Types
Synvisc
Hylagan
Orthovisc
Suparz

26. Positioning

27. Successes!

28. Side Effects
Mild pain caused by injection, usually resolve in three days following injection. (Avoid heat for 24 hours and strenous / weight bearing activity after).
Serious allergic reaction. (Egg based).
How to define (Synvisc) pseudo-sepsis vs injection flare

29. Overall Response to Hylan G-F 20 Viscosupplementation
Much Better
35.0%
Better
42.2%
Same
Worse or
21.4%
Much Worse
1.3%
Reference: Lussier A, Cividino AA, McFarlane CA, et al. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol. 1996;23(9):

30. Reimbusement Always be aware of participating insurance programs.
Seek pre-authorization per insurance
Per Incident “2” guidelines, (would second visit per mid level be covered?)
Purchasing “off shore”.
FDA vs Morality vs Reality.

31. Treatment Who is the best candidate for injection?
When to choose preventive vs operative medicine

32. Osteoarthritis CLINICAL MANAGEMENT OA Treatment Modalities
ACR 2000 GUIDELINES – Pharmacologic/Surgical Therapy
Mild to Moderate Pain
Simple analgesics (eg, acetaminophen)
OTC NSAIDs
Topical creams
Moderate to Severe Pain
COX-2–selective inhibitors (CELEBREX)
Rx NSAIDs plus gastro-protective agent
Additional Therapies
IA hyaluronans
IA steroids
Tramadol
Opioids
Surgical Intervention
Arthoplasty; osteotomy
Total knee replacement
Adapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:

33. Questions?

34. Thank you,
Have a Blessed Day!
&
God Bless America!