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

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Presentation on theme: "“The Art of the Injection” By Jon C. Brillhart PA-C By Jon C. Brillhart PA-C Daivd Lannik MD Portsmouth Orthopedics, Inc."— Presentation transcript:

1 “The Art of the Injection” By Jon C. Brillhart PA-C 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 “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 Diagnostic 1.) Joint Aspiration (confirm nature fluid) 2.) Provide symptom relief of affected body part. Therapeutic Therapeutic 1.) Increase mobility and decrease pain.

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

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

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

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

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

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

11 Equipment Safety (oxygen, anaphylaxis kit, Safety (oxygen, anaphylaxis kit, crash cart, msds) Appropriate needles and syringes Appropriate needles and syringes Medication with “in date” expirations! 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 AgentPotencyDurationDose/Site Hydrocortisone acetateLowShort10 to 25 mg for (Hydrocortone)soft tissue and small joints 50 mg large joints MethylprednisoloneIntermediateIntermediate2 to 10 mg for (Depo Medrol)soft tissue and Triamcinolonesmall joints (Aristocort)10 to 80 mg for large joints Dexamethasone sodiumHighLong0.5 to 3 mg for (Decadron)soft tissue and small joints 2 to 4 mg large joints Betametasone sodiumHighLong1 to 3 mg for soft tissue phosphate and acetateand small joints (Celestone Soluspan)2 to 6 mg large joints

15 Recommended maximum dosages and volumes for joint injections SiteDosageVolume Shoulder30 mg10 ml Elbow20 mg5 ml Wrist, Thumb10 mg2 ml Fingers5 mg1 ml Hip40 mg5 ml Knee40 mg10 ml Ankle, foot20 mg5 ml Toes10 mg1ml

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

17 Local Anesthetics Provide pain relief Provide pain relief May help to differentiate between local and referred pain. May help to differentiate between local and referred pain. Provide fluid volume to the injection Provide fluid volume to the injection Help distribute corticosteroid in large joints Help distribute corticosteroid in large joints May be short or long acting 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!!! Warning!!! Never use epinephrine / lidocaine solution on ears, nose, fingers and toes!!!

20 Onset, Duration, and toxicity of local anesthetics DrugOnsetDurationMax Vol Lidocaine 1%1-2 Min~ 1 Hour20 ml 2%1-2 Min~ 1 Hour10 ml Bupivacaine 0.25%30 Min8 hours60 ml 0.50%30 Min8 Hours30 ml

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

22 Hyaluronic Acid Used to treat OA of the knee Used to treat OA of the knee Act as viscoelastic supplements that replace the diseased synovial fluid of the osteoarthritic joint 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?). 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 Highly influences intercellular matrices of joint soft tissues Unique combination of elasticity and viscosity Unique combination of elasticity and viscosity Hyaluronan responsible for elastoviscous properties Hyaluronan responsible for elastoviscous properties Elastoviscosity critical for joint function Elastoviscosity critical for joint function Elastoviscosity reduced in osteoarthritis Elastoviscosity reduced in osteoarthritis

24 % Elasticity% Viscosity Frequency (Hz) walking running jumping Normal OA Viscosupplementation Basic Principle 500,00 0 hylan G-F 20MW 6 million HA MW

25 Types Synvisc Synvisc Hylagan Hylagan Orthovisc Orthovisc Suparz 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). 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). Serious allergic reaction. (Egg based). How to define (Synvisc) pseudo-sepsis vs injection flare How to define (Synvisc) pseudo-sepsis vs injection flare

29 Overall Response to Hylan G-F 20 Viscosupplementation Much Better 35.0% Same 21.4% Worse or Much Worse 1.3% Better 42.2% 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. Always be aware of participating insurance programs. Seek pre-authorization per insurance Seek pre-authorization per insurance Per Incident “2” guidelines, (would second visit per mid level be covered?) Per Incident “2” guidelines, (would second visit per mid level be covered?) Purchasing “off shore”. Purchasing “off shore”. FDA vs Morality vs Reality. FDA vs Morality vs Reality.

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

32 Osteoarthritis CLINICAL MANAGEMENT OA Treatment Modalities ACR 2000 GUIDELINES – Pharmacologic/Surgical Therapy Adapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43: 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  IA hyaluronans  IA steroids Surgical Intervention   Arthoplasty; osteotomy  Total knee replacement Additional Therapies  Tramadol  Opioids

33 Questions?

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


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