Out Patient Procedures Joint and Trigger point injections Joint Aspiration or Arthrocentesis Hands on workshop

Joint and Trigger point injections Charles Haddad M.D. Associate Professor University of Florida

DISCLOSURES I do not have any disclosures. No financial interest in subject being discussed

OBJECTIVES Upon completion of this activity, participants should be able to: Understand advantages & disadvantages of joint injections. Discuss the indications and contraindications of joint injections. Evaluate different approaches and medications used in joint injections. Improve confidence level of giving joint injection and trigger point injections.

Overview The Basics Who and what should be injected Who and what should not be injected Risks vs. Benefits What you need EPIC Documentation/ Charges HANDS ON WORKSHOP

The Basics ASPIRATION (Arthrocentesis)- inserting a needle into a joint to remove synovial fluid, or blood. INJECTION is usually performed with corticosteroids and a local anesthetic.

The Basics Aspiration and injection of a joint is performed to relieve pressure, decrease inflammation and for diagnosis. Corticosteroids may be injected once it has been established that the inflammation is not secondary to infection. Aspiration of the joint or bursa can obtain fluid for synovial fluid analysis.

The Basics Joint fluid can be sent for: WBCs infection/inflammation Gram Stain infection Crystals gout-negative birefringent urate crystals pseudogout- Calcium Phosphate Dehydrate Crystals (CPPD)

Do steroid injections work? Very few studies support or refute the efficacy of common joint intervention in medical practice Substantial practice based experience support the effectiveness of joint/soft tissue injections Corticosteroid injections should always be viewed as adjuvant therapy eg physical therapy

What can be Injected/Aspirated Clean injuries with effusions Degenerative Joint Disease with synovitis Trigger fingers Trigger points Hemarthrosis Areas of tendonitis

What can be Injected/Aspirated Knees: OA, Gout, Patellar bursitis, Meniscus injury Elbows : Lateral epicondyle tendonitis, Olecranon Bursa Shoulders : OA, Rotator cuff tendonitis, Frozen shoulder, Subchromial Bursitis Wrists : Carpal tunnel, DeQuervain tenosynovitis

What can be injected/Aspirated Fingers/Thumb especially with trigger finger Hip: Trochanteric Bursitis Ganglion Cysts Trigger Point injections

Who and What should NOT be injected Any areas suspected to be infected Acute Fractures Prosthetic Joints Impending Joint replacement (within a few days)

Who and What should NOT be injected Patients with uncontrolled bleeding disorders or uncontrolled diabetes Achilles Tendon Any ropey tendon Not as successful in the hip joint except at the trochanteric bursa

More commonly seen Risks and ways to avoid Fat necrosis : deeper injection avoid subcutaneous fat Patches of hypo pigmentation(especially with dark skin) deeper injections help to avoid Elevations in blood sugar(transient from several to 21 days ) Monitor sugars more closely after injection, may need to adjust meds

Risks and ways to avoid Pain: can be improved with ethyl chloride or distraction techniques Infection (< 0.01%) : using sterile/clean techniques Bleeding : avoid vascular structure Tendon rupture: do not inject into the tendon itself

More Risks and ways to avoid Long term effects if done too frequently is the same as chronic use of corticosteroids(weight gain, osteoporosis, high sugars). Vasovagal reaction (frequent ~10%): perform injections in supine position if possible If local anesthetic is injected into the vessel it can cause a toxic reaction(heart arrhythmias):avoid intravenous injection/aspirate

More Risks and ways to avoid Post injection flair(increased pain for several days after the injection) : icing the area down after the injection White blood cell margination, transient increase in WBCs

Benefits Decreases pain: improve mobility for physical therapy Decreases pressure: especially with aspiration Decreases inflammation Improves range of motion Effects are seen quickly(usually within a few days)

Frequency(keep it simple) No more frequently than every 2-3 months No more than 2-3 time a year Some clinicians recommend a lifetime limit

What you need For preparation and skin anesthesia Cleaning solution- usually povidone- iodine solution A drape (sometimes) Sterile gloves Small syringe~ 1-3ML to anestitize the skin 18 gauge needle to draw the local anesthetic and 25-30 gauge needle to inject 1% Lidocaine without epinephrine

What you need For Aspiration 18 gauge 1 ½ inch needle 20 ml syringe for larger joints 5-10 ml syringe for smaller joints

What you need For Corticosteroid injections 22 gauge 1 ½ inch needle 5-10 ml syringe The Corticosteroid solution 1% Lidocaine without epinephrine Inject within a few minutes of mixing to avoid crystallization

How much to give (Keep it simple) Large Joints 40 mg Triamcinalone Small Joints 10-20 mg Triamcinalone Large joints; knees, shoulders, etc. add 4cc of Lidocaine 1% without epi Smaller joints e.g. wrist, elbows add 2ccs of Lidocaine Fingers, hand add 1cc of Lidocaine

NOTE: Steroid agents listed in order of prevalence of use. Commonly Used Steroids STEROID DOSING AND EQUIVALENTS Steroid Common concentration (mg per mL) Common equivalent dose* (mg) Approximate duration of action (days) Methylprednisolone acetate (Depo-Medrol) 40 or 80 40 8 Triamcinolone acetonide (Kenalog) 10 or 40 14 Triamcinolone hexacetonide (Aristospan) 20 21 Dexamethasone acetate (Decadron LA†) Dexamethasone sodium (Decadron†, Solurex†) 4 6 NOTE: Steroid agents listed in order of prevalence of use.

Commonly Used Local Anesthetics LOCAL ANESTHETICS OR JOINT INJECTION Medication Onset of action (minutes) Duration of action (hours) Max volume of injection* 0.25% Bupivacaine (Marcaine) 30 8 60 mL 0.5% Bupivacaine 30 mL 1% lidocaine (Xylocaine) 1 to 2 1 20 mL 2% lidocaine 10 mL *— Increased risk of cardiac toxicity or arrhythmia above these dosages.

Synvisc Hylan G-F 20 An elastoviscous high molecular weight fluid containing hylan A and hylan B Produced from chicken combs Hyaluronan is a long chain polymer

Synvisc Hylan G-F 20 Indication: treatment of pain in osteoarthritis of the knee in patients who have failed to respond to conservative therapy Contraindication: patients who are hypersensitive or allergic to hyalurornan patients who have joint or skin infections in the injection site Precautions Patients allergic to egg products and avian proteins

Synvisc Hylan G-F 20 Technique: 2 mL Synvisc is injected intr-articularly into the knee joint once a week for three weeks Strict aseptic technique must be followed 18-22 gauge needle is used Same needle can be used to drain joint and inject Synvisc Effectiveness in other joints has not been established

Synvisc Hylan G-F 20 Adverse effects: most commonly knee pain, swelling, and joint effusion

QUESTIONS????

HANDS ON WORKSHOP