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

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

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

4. 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.

5. 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

6. 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.

7. 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.

8. 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)

9. 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

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

11. 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

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

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

14. 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

15. 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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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 gauge needle to inject
1% Lidocaine without epinephrine

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

24. 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

25. How much to give (Keep it simple)
Large Joints 40 mg Triamcinalone
Small Joints 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

26. 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.

27. 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.

28. 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

29. 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

30. 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

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

36. QUESTIONS????

37. HANDS ON WORKSHOP