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Gregory C. Gardner, MD, FACP Gilliland-Henderson Professor of Medicine

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Presentation on theme: "Gregory C. Gardner, MD, FACP Gilliland-Henderson Professor of Medicine"— Presentation transcript:

1 Apply Evidence Based Medicine to Arthrocentesis Skills: Shoulder and Knee
Gregory C. Gardner, MD, FACP Gilliland-Henderson Professor of Medicine University of Washington, Seattle, WA

2 Evidence Based References
Courtney and Doherty. Best Practice & Research Clinical Rheumatology 2009; 23:161–192 (2013 update) Crawshaw DP et al. Exercise therapy after corticosteroid injection for moderate to severe shoulder pain. BMJ 2010;340:c3037 doi: /bmj.c3037 Raynauld JP, et al. Safety and efficacy of long-term intraarticular steroid injections for osteoarthritis of the knee. Arthritis Rheum 2003;48: Habib GS, et al. Local effectes of intra-articular corticosteroids. Clin Rheumatol 2010;29: Gardner GC. Teaching arthrocentesis and injection techniques: what is the best way to get our point across. J Rheumatol 2007 vol. 34 (7) pp

3 Outline of Workshop Didactics Surface anatomy
Procedure pearls Anatomy review Clinical Issues and technique review Surface anatomy Present evidence based best practices

4 Current status of how we do and teach arthrocentesis and injection therapy

5 Dangers of “Evidence based Medicine”

6 Analytic rubric Procedure distilled into discrete steps:
1. Patient counseling Discuss reasons for doing the procedure Discuss details of doing the procedure Discuss potential side effects Inquire about potential contra-indications 2. Patient preparation Able to verbalize anatomy and mark appropriate location Patient positioned properly for site of procedure Skin cleansed properly Appropriate application of anesthesia

7 Analytic rubric continued
3. Needle insertion Choose appropriate needle and syringe for procedure Needle inserted at appropriate angle/depth Needle/syringe stabilized during procedure Aseptic technique 4. Post-procedure wrap-up Skin re-cleansed if necessary, site bandaged Post-procedure counseling provided Sharps disposed of properly Operator showed concern for patient comfort

8 Utility of Rubric Framework for teaching arthrocentesis skills
Can be used to think about and applying evidenced-based principles Useful as assessment tool for physicians in training Useful as a documentation of procedure competency

9 Procedure Pearls

10 Textbook complications of arthrocentesis & injection therapy; How much should we worry?
Charcot arthropathy – very rare; why would it develop and how often can we safely inject an joint? Periarticular calcifications – 4% give or take may develop Infection – very rare (TBD) Post-injection synovitis – uncommon; 6-12 hrs following procedure and resolves in 48 hrs Tendon rupture – rare; avoid injecting tendon especially high tension tendons i.e. Achilles Skin depigmentation – 5%; may develop 8 wks after injection and resolve by 16 wks Subcutaneous fat atrophy – up to 8%; avoid placing corticosteroid in subcutaneous fat Other – AVN, hyperglycemia, flushing

11 Textbook contraindications to injecting corticosteroids into joints and soft tissue
Infection or suspected infection around the joint Avoid injecting through psoriatic plaque Hypersensitivity to injectables Most “hypersensitivity” is to epinephrine; no need to use Upcoming surgery on the joint TBD Suspected intra-articular fracture/joint instability Anticoagulation Caution not contraindication; TBD

12 Joint procedures and infection
Seror et al Rheumatology 1999 Retrospective study involving 69 French rheumatologists Mean number of years in practice 20.9 Mean number of corticosteroid injections per year 809 Total injections 1,160,000 in 20 years with 15 instances of post injection infection Overall rate of infection was 1/77,300 When pre-packaged CS syringes used: 1/162,000 When multi-dose vial used: 1/21,000 (7.7 X higher!) 1/4.6 rheumatologists had post-injection septic complication over 20 years Two points: Infection is rare with arthrocentesis and injection therapy Issue of multidose vial especially where used by people not as thoughtful as you about sterile technique Hollander series of 16 infections per 150,000 procedures = 1/9300

13 How often can we inject a knee?
68 knee OA pts randomized to either saline or 40 mg of triamcinolone acetate injections every 3 months for 2 years Double blind study After 2 years of therapy, no difference in joint space width between groups (figure) Joint pain at night and stiffness significantly better for steroid group using AUC analysis at 2 years Conclusion: JS not affected Clinical improvement especially at 1 year, less apparent at 2 yrs No significant SE Raynauld et al. Arthritis Rheum 2003;48:370

14 Steroid injection into hip prior to THA Chitre et al. JBJS 2007
99 pts had received steroid/local anesthetic into hip joint 4 to 50 mo prior to THA; mean 18 mo Follow-up 25.8 mo post-surgery with range 9-78 mo NO instances of post-operative joint infection or sepsis occurred Similar data from Sankar et al and Sreekumar et al in the hip and Desai et al in the knee Data from McIntosh et al raise concern about infection if given within 6 weeks of surgery (trend but NS) McIntosh et al. Clin Orthop Relat Res 2006

15 Best way of cleansing the skin?
Current evidence based guidelines for inserting IV catheters suggests the following is best practice according to EPIC 2, a mega- systematic review of best practices for prevention of catheter associated infections Decontaminate the skin site with a single patient use application of alcoholic chlorhexidine gluconate solution (preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol) prior to the insertion of a central venous access device. (Class A) Use a single patient use application of alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter (Class D) Granted indwelling catheters but…. Like Chlorhexidine alcohol preps easy to use, no yellow-brown stuff to remove stain clothing; does erase any pen marks you put on the skin so need pressure mark of landmark Journal of Hospital Infection (2007) 65S, S1–S64

16 Arthrocentesis and anticoagulation? Ahmed and Gertner Am J Med 2012
Retrospective review of complication in 640 arthrocentesis in 514 anticoagulated patients Compared the incidence of significant bleeding in patients by INR (>2 or < 2) Conclusion: no need to reduce anticoagulation level prior to procedures Complication INR >2 N=456 INR < 2 N=184 Early Bleeding 1 (0.2%) Late Bleeding Infection Pain 3 (0.7%) Comparisons between groups NS Patient with bleeding also had pain

17 Should I use anesthesia prior to a procedure?
Park et al Rheumatol International 2009 99 patients underwent 2 arthrocenteses One without and one with anesthesia Procedures performed with: Conventional syringe or Reciprocating procedure device Pain measured on 10 cm VAS (0 no pain; 10 unbearable pain) Conventional syringe Reciprocating syringe P # of subjects 49 50 Pain w/o anesthesia 9.22 9.39 NS Pain of anesthesia 6.18 3.96 .006 Pain after anesthesia 4.10 1.84 .003 % Pt wanting anesthesia 100% NA Besides pain literature also indicated that anesthesia reduces procedure anxiety Do not understand by the RPD would produce less local anesthesia pain?

18 Benefit of buffering lidocaine
Lidocaine maintained at acidic pH to increase shelf life; pH 6.2 preventing photodegradation/aldehyde formation; lidocaine-epinephrine has even lower pH (5.98) Sodium bicarbonate neutralizes pH (7.2) but does not affect onset of action; increases efficacy via increasing uncharged form of drug Buffering: 1 part (1mEq/ml) sodium bicarbonate to 10 parts lidocaine Consistent literature favoring buffering: Vasectomy Bone marrow Bx IV cannula insertion Laceration repair Etc.. We only get the 50 ml single use vial of NAHCO3 Cristoph et al. Ann Emerg Med 1988;17:

19 Cristoph et al. Ann Emerg Med 1988;17:117-120
Pain scores on VAS following intradermal infiltration of unbuffered and buffered local anesthesia Pain on VAS 6.21 7.22 5.98 7.16 6.18 7.20 pH noted Cristoph et al. Ann Emerg Med 1988;17:

20 18 gauge in articular cartilage
Needles: Primum non nocere or Gardner’s rule 23 “use the smallest needle necessary to get the job done” 25 Gauge 22 Gauge Aspirating knees with 18 gauge easier for physician but potentially more painful and injurious for patient 18 Gauge 18 gauge in articular cartilage John Clark, MD, PhD

21 New ways of doing procedures
Dual Injector Three Way Stop Cock Simkin Method Simkin 3 way stopcock Dual injector one way valve so as not to mix contents (talk about this in few minutes) will not take a luer lock syringe RPD developed at U New Mexico better needle control no need to pull back on plunger always pushing to aspirate and to inject New ways of doing procedures Reciprocating Procedure Device

22 Which is he best corticosteroid preparation?
Triamcinolone (Aristospan, Kenalog) - easily goes through gauge needles, Methylprednisone Acetate (Depomedrol) - floculant, may require larger than 30 gauge needle. Betamethasone Acetate (Celestone Soluspan) - mixture of short and long acting preparation Dexamethasone Acetate (Decadron-LA) - Long acting, frequently mixed with Decadron for short and long acting combination Only head to head trial of TCA 20 mg vs MPA 40 mg in knee OA - TCA better pain relief, MPA lasted longer In 2 small trials of TCA vs MPA in RA, TCA lasted longer Pyne D, et al Clin Rheumatol 2004;23:

23 Can we mix anesthetic and steroids?
Dogma about not “mixing” local anesthetic with steroids especially methylprednisolone; 74% of us do mix Preservative parabens may cause steroid to appear flocculant HPLC study to determine stability of mixed contents for epidural injections Conclusion: mix away! Percent drug remaining after time noted by HPLC Formula 1 Triamcinolone Bupivicaine Iohexol 4 hours 93% 101 103 24 hours 97 99 Formula 2 Lidocaine 85 91 Formula 3 Methylprednisolone 88 104 86 98 Formula 4 102 93 Trouble recovering all of steroid as suspension rather than a solution Do not state whether preservative free Shat et al. BJ Radiology 2009;82: Stored at 370

24 Why do patients with acute onset joint effusions keep their joint at of flexion? Boyles Law of course! Boyles Law: Pressure is inversely proportional to volume when temperature is constant in a closed system pV=C

25 Hochberg et al. Rheumatology 3rd edition
Joint position and intra-articular pressure: Maximum joint volume between of flexion Hochberg et al. Rheumatology 3rd edition

26 Practice Point: Three causes of severe joint pain
There are three causes of joint pain so severe that the patient will guard the joint and protect against movement BUGS BLOOD CRYSTALS Patients hold their joint 300 of flexion as this represents maximum joint volume; flexion or extension results in reduced volume thus increased pressure Slowly developing joint effusions allow time for the capsule to distend and thus do not cause the same degree of pain BBC Joint

27 Convex vs Concave Joint Surfaces
Electronic Textbook of Hand Surgery Carpus Direction of Needle Convex Concave Radius Ulna Radius Ulna

28 Making your own polarizing microscope

29 Synovial Fluid Findings
Only a small amount of synovial fluid is necessary to make the diagnosis of crystalline forms of arthritis; important to crystal prove at least once

30 Scope and Kit

31 Placing Polarizer and Analyzer

32 Crystals

33 Shoulder Subacromial Region

34 Shoulder Anatomy Osseous structures Scapula Scapular spine Acromium
Glenoid Coracoid Clavicle Humerus

35 Shoulder Anatomy Important muscles Important joints Other Deltoid
Rotator Cuff Scapular stabilizers Important joints Glenohumeral Acromioclavivular “Scapulothoracic” Other Redundant capsule Subdeltoid bursa

36 Glenohumeral Joint: Circle of Stability
Long head of biceps tendon Note pear shaped glenoid that allows humeral head to be depressed by RTC muscles

37 Shoulder Joint Capsule
Capsule distended Grays Anatomy

38 External rotation view
Suggested X-rays: Internal rotation External rotation Axillary view External rotation view Axillary view Mike Richardson, M.D.

39 Dx in 101 Patients with Shoulder Pain Over 18 Months in Internal Medicine Clinic
Diagnosis Percent Rotator Cuff Disease 62 Myofascial Pain 22 Adhesive Capsulitis 10 AC Joint OA 4 Bicepital Tendonitis 3 RA/OA/RSD/PMR 1 each Anderson, Kaye. West J Med 1983; 138:268

40 Neer CS, 2d. Impingement lesions. Clin Orthop 1983; 173:70
Impingement Syndrome Impingement is caused by compression of the rotator cuff tendons and subacromial bursa between the greater tubercule of the humerus and the lateral edge of acromion; direct trauma vs impairment of blood supply? 3 stages of impingement syndrome described by Neer Stage 1 - Edema and hemorrhage Stage 2 - Cuff fibrosis, thickening, and partial cuff tearing Stage 3 - Full thickness tendon tears, bony changes, and tendon rupture. Neer CS, 2d. Impingement lesions. Clin Orthop 1983; 173:70

41 Posterolateral Injection of the Subacromial Space
Behind humeral head, under the acromium, directed toward the AC joint 25 gauge, 1 1/2 inch needle Anesthesia with 3-4 cc 1-2% lidocaine useful as diagnostic test Inject with 2 cc bupivicaine & mg of depomedrol or triamcinalone

42 Lateral Subacromial Injection
Palpate AC joint Identify acromion 1 cm below acromion; angle under AC joint

43 Subacromial Injection: Lateral vs Posterolateral

44 Note how patient is elevating arm?

45 Injection + exercise vs exercise alone for RTC tendonitis
227 pts randomized to injection + exercise vs exercise alone for impingement syndrome; mean 16 wks of pain 20 mg of triamcinolone plus lignocaine Exercise individualized; attended as many PT sessions as necessary Outcome: 1 & 6 wks pain/disability scores significantly better for injection At 12 & 24 wks NO difference between groups At later assessments, exercise only group taking more pain meds & 32% were injected at some time between 12 and 52 wks Conclusion: Injection therapy provides early pain improvement in impingement syndrome One-third of exercise only patients go on to injection Crawshaw et al BMJ 2010

46 Do repeated injections lead to RTC tears?
230 patients who had had an MRI scan for impingement symptoms retrospectively evaluated for frequency of RTC tears by number of subacromial steroid injections 128 had 0-2 injections, 102 had 3 or more Exclusions: age > 70, trauma, RA, Diabetes Results: Conclusion: repeated injections NOT associated with RTC tears More full thickness tears in fewer injection group?? 0-2 injections 3 or more RTC tears 65 (50.8%) 48 (47%) Partial thickness 12 21 Full thickness 50 24 Massive tear 3 Ann R Coll Surg Engl 2009; 91: 414–416

47 Does a corticosteroid injection help in adhesive capsulitis and if so does it matter where we put it? 191 pts with adhesive capsulitis randomized to 4 groups; all received progressive PT Subacromial steroid injection (40 mg TCA) Glenohumeral steroid injection Combination injection using same total steroid dose NSAID At 16 weeks steroid groups significantly less pain and improved motion compared to NSAID only At 24 weeks no difference b/w groups Did not matter where the steroid was placed (US guided) Shin SJ, Lee SY. J Shoulder Elbow Surg 2013;22:

48 Knee

49 Knee anatomy Important points:
Synovial space extends above patella; large target Synovial space posterior to knee joint as well; may explain why patients have posterior pain with an effusion Gray’s Anatomy

50 Menisci Bursae ACL PCL Infrapatellar Fat Pad Menisci Joint Capsule

51 Shape of Patella Femoral Condyles Note “keel” of the patella
Patella, Lateral Shape of Patella Patellar Groove (Femoral Sulcus) Axial View of Knee Visible Human Femoral Condyles MultiMedia Group, used with permission Note “keel” of the patella Purpose of patella?

52 Lateral Medial Suprapatella

53 Lateral Medial

54 Lateral Medial

55 Lateral Medial Note tissue thickness medial vs lateral

56 Lateral Medial Note ridge on lateral femur Midpatella

57 Lateral Medial Note concave v convex relationship of PFJ

58 Lateral Medial

59 Reasons to aspirate or inject a knee
Confirm inflammatory arthritis/crystalline arthritis R/O septic arthritis (knee most affected joint) Relieve pressure in OA/inflammatory arthritis Inject Treat inflammatory arthritis with IA steroids Inject steroids/hyaluronic acid for OA Equipment 21-22 gauge needle for aspiration (18??) 25 gauge to inject only 20-40 mg of triamcinolone or depomedrol Like celestone soluspan for gouty arthritis when available

60 Knee approaches There are at least 4 different routes utilized to enter the knee joint Medial mid-patellar Lateral supra-patellar Anteromedial or anterolateral Lateral mid-patellar Each route has their proponents but it is important to be be familiar with several as some patients will not be easily approached via your most comfortable route

61 Medial knee approach Medial approach is particularly useful when there is a small effusion Identify the superior and inferior poles of the patella Mark a location 1/3-1/2 down from the superior pole and just below the medial margin of the patella Angle needle slightly inferior and a bit superior to miss the patellar keel Make sure you look at the patient’s foot; the needle should be generally perpendicular to the foot Courtney & Doherty: Best Practice & Research Clinical Rheumatology. 2009

62 Superolateral knee approach
This approach is useful for large effusions Mark the area where the superior and lateral margins of the patella meet Angle the needle down and medially into the joint space Courtney & Doherty: Best Practice & Research Clinical Rheumatology. 2009

63 Anterior approaches for knee injections
Patella This approach can be done from either the medial or lateral surface Identify the patellar ligament then the tibial plateau Generally there is a “soft spot” that identifies the area adjacent to the ligament and just above the tibial plateau Angle the needle toward the center of the knee Medial edge of patellar ligament Tibial plateau

64 Anterior approach “Soft spot” Needle directed toward center of knee
Not recommended for aspiration

65 Lateral Midpatellar Approach
Remember MRI scan Suggest inserting needle no further than 1/2 the way down the lateral patellar margin Tissue to traverse is thin laterally and can use 1” needle in normal sized person John Clark is using butterfly needle in this picture John Clark MD, PhD

66 Bilateral knee effusions
Note loss of medial concavity and bulging suprapatellar pouch

67 Anesthesia with 1-2% lidocaine without epinephrine (what is wrong with this picture?)
Note marks on knee

68 Aspiration with 21-22 gauge needle and 20-30 cc syringe

69 Using mosquito clamp to change from aspiration to injection syringe

70 Injecting with 40 mg of triamcinolone or depomedrol +/- mixed with small amount of local anesthetic

71 Clean, bandage, bed rest x 24 hr

72 Jackson et al. JBJS 2002;84-A:1522-27
Accuracy of knee injection into non-effused joints by location of injection 240 knee injected for OA done by one orthopaedic surgeon into knees without effusions Three approaches; anteromedial, anterolateral, and lateral mid-patellar Placement of injected material confirmed by fluoroscopy Accuracy: Anteromedial: 60/80 in joint space (75% accuracy) Anterolateral: 57/80 in joint space (71% accuracy) Lateral mid-patellar: 74/80 in joint space (93% accuracy) Jackson et al. JBJS 2002;84-A:

73 Aspirate or not aspirate RA knee before steroid injection?
191 swollen RA knees randomized to receive 20 mg of triamcinolone following: Complete aspiration of fluid No aspiration of fluid Followed 6 mo primary end point recurrent knee swelling Groups balanced with regard to gender, medications, prednisone use, ESR etc. Primary end point: Relapses in 23% of aspirated knees Relapses in 47% of non-aspirated knees (p = .001) Medications changed in similar % of pts during study period Weitoft & Uddenfeldt. Ann Rheum Dis 2000; 59:233

74 Should an RA knee be rested following injection?
Old dogma: bed for 2-3 days and then use crutches for 2-3 wks Chakravarty et al Br J Rheum 1994 Randomized 91 Pts with inflammatory knee arthritis to 24 hr of in hospital rest or usual activity after 40 mg of triamcinolone hexacetonide & 2 cc of lignocaine in knees aspirated to dryness VAS pain, knee circumference, 50 foot walk time, CRP followed at 3, 6, 12 and 24 months Results - both improved at 3 wks; RG showed highly significant improvement through 24 wks compared to NRG in all of the study variables; 8 NRG & 2 RG Pts required reinjection Conclusion - 24 hr of bed rest improves clinical outcome for inflammatory arthritis patients (OA pts as well?)

75 Conclusion Make sure our patients are well informed about the procedure process If unsure, review basic anatomy before procedure Be careful but remember that serious adverse events are very rare Evidence based approach will hopefully turn a “wild west” approach to arthrocentesis and injection into a more orderly process!


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