Presentation on theme: "“The Art of the Injection”"— Presentation transcript:
1 “The Art of the Injection” By Jon C. Brillhart PA-CDaivd Lannik MDPortsmouth 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 Diagnostic1.) Joint Aspiration (confirm nature fluid)2.) Provide symptom relief of affected body part.Therapeutic1.) Increase mobility and decrease pain.
5 Indications for Diagnostic and Therapeutic Injections Soft Tissue conditionsBursitisTendonitis or tendinosisTrigger pointsGanglion cystsNeuromasEntrapment syndromesFasciitis
6 Indications for Diagnostic and Therapeutic Injections Joint ConditionsEffusion of unknown origin or suspected infection.Crystalloid arthropathiesSynovitisInflammatory arthritisAdvanced osteoarthritis
7 Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections Absolute contraindicationsLocal cellulitisSeptic arthritisAcute fractureBacteremiaJoint prosthesisAchilles or patella teninopathiesHistory of allergy or anaphylaxis to injectable constituents
8 Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections Minimal relief after two previous injectionsUnderlying coagulopathyAnticoagulation therapy(avoid soft tissue injection)Evidence of surrounding joint osteoporosisAnatomically inaccessible jointsUncontrolled diabetes mellitus
9 Top Six Injections Chronic subdeltoid bursitis Shoulder capsulitis Knee osteoarthritisTennis elbowTrapezio metacarpel joint OAPlantar 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 syringesMedication 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 CorticosteroidsSynthetic 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/SiteHydrocortisone acetate Low Short 10 to 25 mg for(Hydrocortone) soft tissue andsmall joints50 mg large jointsMethylprednisolone Intermediate Intermediate 2 to 10 mg for(Depo Medrol) soft tissue andTriamcinolone small joints(Aristocort) to 80 mg forlarge jointsDexamethasone sodium High Long 0.5 to 3 mg for(Decadron) soft tissue and smalljoints2 to 4 mg large jointsBetametasone sodium High Long 1 to 3 mg for soft tissuephosphate and acetate and small joints(Celestone Soluspan) to 6 mg large joints
15 Recommended maximum dosages and volumes for joint injections Site Dosage VolumeShoulder 30 mg 10 mlElbow 20 mg 5 mlWrist, Thumb 10 mg 2 mlFingers 5 mg 1 mlHip 40 mg 5 mlKnee 40 mg 10 mlAnkle, foot 20 mg 5 mlToes 10 mg 1ml
16 Side-effects of steroid injection therapy Systemic side-effectsFacial flushingMenstrual irregularityImpaired diabetic controlEmotional upsetHypothalmic – pituitary axis suppressionFall in ESR/CRPAnaphylaxisLocal side-effectsPost injection flare of painSkin depigmentationSubcutaneous atrophyBleeding / bruisingSteroid “chalk”Soft-tissue calcificationSteroid arthropathyTendon rupture or atrophyJoint / soft-tissue infection
17 Local Anesthetics Provide pain relief May help to differentiate between local and referred pain.Provide fluid volume to the injectionHelp distribute corticosteroid in large jointsMay 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 VolLidocaine1% 1-2 Min ~ 1 Hour 20 ml2% 1-2 Min ~ 1 Hour 10 mlBupivacaine0.25% 30 Min 8 hours 60 ml0.50% 30 Min 8 Hours 30 ml
21 “A Failure of the Supporting Structure of the Total Organ (Joint)” CHANGES ASSOCIATED WITH OSTEOARTHRITISJoint injury or deformity1Imbalance of biosynthesis and degradation in cartilage, synovial fluid, bone, muscle, ligaments1Inflammation1Chronic wear and age1Softening and loss of articular cartilage1Decrease 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 jointAct as a shock absorber and lubricates the joint! (How to explain this to pt?).
23 Synovial FluidHighly influences intercellular matrices of joint soft tissuesUnique combination of elasticity and viscosityHyaluronan responsible for elastoviscous propertiesElastoviscosity critical for joint functionElastoviscosity reduced in osteoarthritisSlide 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.11. 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 1009010Slide 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.11. 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; 1983:8020hylan G-F 20MW 6 million703060Normal40% Elasticity% Viscosity50OA5040603070running2080walkingjumping1090HA MW500,0001000.010.111020Frequency (Hz)
28 Side EffectsMild 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 Better35.0%Better42.2%SameWorse or21.4%Much Worse1.3%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 insurancePer 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 TherapyMild to Moderate PainSimple analgesics (eg, acetaminophen)OTC NSAIDsTopical creamsModerate to Severe PainCOX-2–selective inhibitors (CELEBREX)Rx NSAIDs plus gastro-protective agentAdditional TherapiesIA hyaluronansIA steroidsTramadolOpioidsSurgical InterventionArthoplasty; osteotomyTotal knee replacementAdapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43: