Clinical Musculoskeletal Injections Chris Parfitt MD FRCS©

Disclosures none (I like giving injections)

Musculoskeletal Injections A bit like moose hunting Chasse l’orignal

Moose Hunting Hunting licence Right animal (moose) Right caliber rifle Right type of bullet YOU HAVE TO HIT THE TARGET

Musculoskeletal Injections Medical licence Right diagnosis Right needle Right dose of medicine YOU HAVE TO HIT THE TARGET

MSK Injections General Informed consent Procedure Benefits Risks In writing or verbal ALWAYS ASK ABOUT ALLERGY!!

MSK Injections General The equipment Antiseptics bandages

MSK Injections General Equipment Assorted long and short acting local anesthetics With and without epinephrine

Types of Cortisone Triamcinolone 40 mg cc (potency 5) Methylprednisone 40 mg/cc (potency 5) Betamethasone 6 mg /cc ( Potency 25) Kenalog Depomedrol Celestone

SAFETY of WHAT we INJECT Currently no strongly stated rules about what we inject into a joint BUT!!!

Steroid shots and blood sugar No effect Increases blood sugar Methylprednisolone 40 mg Triamcinolone 40 mg betamethasone

PAIN PUMPS Used post operatively starting about 2002 Marcaine with epi

Bupivacaine and Chondrolysis Bupivocaine epinephrine infusion pumps caused high rates of chondrolysis 2005 to 2008

Bupivacaine Chondrolysis Now a whole crop of pain pump lawsuits

Injections and Chondrotoxicity Apoptosis of chondrocytes is a validated measurement of chrondrocyte toxicity

Injections and Chondrotoxicity prednisolone cause chondrocyte death in ex vivo chondrocytes, betamethasone did not Farkas et al CORR 2010 All local anesthetics caused chondrocyte death Dose and time related Farkas et al CORR 2010

Injections and chondrotoxicity All local anesthetic toxicity to chondrocytes potentiated with epiniphrine

Injections and Chondrotoxicity The combination of cortisone and local anesthetic is possibly synergistic in causing chondrotoxicity

Chondrotoxicity: current recommendations Although common practice is to inject steroid and local anesthetic together There are no specific recommendations in the literature

Injections and Chondrotoxicity Intuitively? Use .5% lidocaine, .25% bupivocaine Use bupivocaine, also prednisolone Inject steroid with saline

Injections and Chondrotoxicity If joint already bone on bone, there are no chondrocytes to be toxic to, therefore longer acting local anesthetic can be used!

Injections: Tenocyte toxicity Some studies show tenocyte toxicity with steroids and local anesthetic More dilute local anesthetic less toxic

MSK Injections General Assorted syringes Preneedled syringes are time saving Draw up solution with larger needle demo

MSK Injections Needle size 1.5 inch 25 gauge for fine injections 1.5 inch 21 gauge is optimal for larger joints (shoulder and knee)

MSK Injections General Triamcinolone 40 mg mil Methyl prednisone 40 mg miL Betamethasone 6 mg mil

MSK Viscosupplementation Hyaluronic acid now just over 200$ Approved for arthitis (mostly knee studies)

PLATELET RICH PLASMA Becoming more common Cost from 400 to 800$

PRP Soft tissue Cochrane review 2014 Insufficient evidence to support use for MSK soft tissue injuries and tendopathies

PRP Knee arthritis General concensus is that PRP injections as good Or slightly better than Hyaluronic acid and saline injection More side effects AAOS March 2015

MSK Injections Technique One needle (mixed) Two needles (prefreezing) Less experienced should prefreeze

MSK Injections Technique Betadine best as you can see where it is demo Wait until it dries (until the screaming stops) Prep, then prepare the injection

Tricks of the trade Assess resistance for injections into space DO NO HARM Need large bore needle to draw up solutions demo

MSK Injections: New kid on the block Ultrasonically guided injections Rapidly becoming more common Need US machine and training Price of US machine decreasing Not discussed today

TRIGGER FINGER INJECTIONS Evidence based ANN RHEM DIS 2008 sept;7(9) 1262-1266

Trigger Finger .5cc steroid 1 – 2 cc local anesthetic Don’t inject into the tendon Inject into or around synovial sheath

Trigger Finger HOT OFF THE PRESS Peri pulley injection had higher success rate than intra sheath injection

Basal Joint arthritis CMC joint arthritis

Basal Joint Arthritis Slight traction Prefreezing very helpful .5 cc steroid (20mg) 1cc of local anesthetic marcaine E

De Quervains Disease Evidence based BMC MSK disorders 2009 Oct 27;10;131 .5 to 1 cc steroid (20 – 40 mg) 2cc to 3 cc local anesthetic

De Quervain’s Disease Inject into or around the sheath

Tennis Elbow Evidence that cortisone is beneficial for at least short term relief

Tennis Elbow Use 3 to 5cc, marcaine with epi 40 mg cortisone Inject the extensor origin Use single needle Patient leaves office pain free

Shoulder Injections Cochrane summary says no better injection success with clinical vs ultrasound guided injection (for now)

Shoulder Injections Rotator Cuff Tendinitis or tear in elderly Evidence based Duration of benefit variable in different studies

Shoulder Injections Subacromial injection Use 2 cc of steroid (80) mg with 8 cc of long acting local anesthetic Posterior, slide needle under acromion

Shoulder Injections Arthritis or frozen shoulder 8cc marcaine with epi, 1-2 cc steroid (40 to 80mg)

Shoulder Injections Glenohumeral injection Posterior, in soft spot Arm internally rotated

Trochanteric Bursa injections Evidence based Journal rheum. 1996 Dec;23;(12) 2104-6

Trochanteric bursitis Large joint 2cc 80 mg steroid 8cc marcaine with epi Lateral position, hip extended Long needle Marcaine with epi Single needle

Knee injections Evidence based Cochrane database Both steroids and viscosupplemtation

Knee injections Large joint Use 2 cc steroid (80 mg) 8cc anesthetic/saline .5% lidocaine, .25% marcaine Lateral subpatellar approach

Knee Injection Leg extended Relaxed Pull kneecap laterally Needle goes under the superior patella Great for aspiration

Knee injection: Preaspiration? One study on RA patients demonstrates better response with preaspiration for steroid injections Weitoff, Journal rheumatic dis. 2000

Hallux Rigidus Injection Arthritis great toe No good studies on this Lots of personal positive experience

Hallux rigidus injection Better done with 2 needle (prefreeze) 25 gauge needle Small joint 1cc marcaine E and less than one half cc steroid

MSK Injections Questions