1. Lower Extremity Workshop Gil C. Grimes, MD February 22 nd 2007

2. Objectives Indications for aspiration and injections Contraindications to aspiration Contraindications to injection Medications Tests to consider Adverse reactions and complications Techniques

3. Indications for Arthrocentesis Crystal-induced arthropathy Hemarthrosis Limiting joint damage from an infectious process Symptomatic relief of a large effusion Unexplained joint effusion Unexplained monarthritis

4. Contraindications for Aspiration Bacteremia Clinician unfamiliar with anatomy of or approach to the joint Inaccessible joints Joint prosthesis Overlying infection in the soft tissues Severe coagulopathy Severe overlying dermatitis Uncooperative patient

5. Contraindications for Injections Adjacent osteomyelitis Bacteremia Hemarthrosis Impending (scheduled within days) joint replacement surgery Infectious arthritis

6. Contraindications for Injections Joint prosthesis Osteochondral fracture Periarticular cellulitis Poorly controlled diabetes mellitus Uncontrolled bleeding disorder or coagulopathy Failure to improve with prior injections

7. Medications Considerations Duration of effect (related to solubility) Potency of steroid Mineralocorticoid effects Hydrocortisone acetate (Hydrocortone) Low potency Short 10 to 25 mg for soft tissue and small joints 50 mg for large joints

8. Medications Methylprednisolone acetate (Depo- Medrol) or triamcinolone acetonide (Aristocort) Intermediate potency Intermediate duration 2 to 10 mg for soft tissue and small joints 10 to 80 mg for large joints

9. Medications Betamethasone sodium phosphate and acetate (Celestone Soluspan) High potency Long duration 1 to 3 mg for soft tissue and small joints 2 to 6 mg for large joints

10. Medications Dexamethasone sodium phosphate (Decadron) High potency Long duration 0.5 to 3 mg for soft tissue and small joints 2 to 4 mg for large joints

11. Steroid Agents

12. Anesthetic Agents Use higher concentration smaller volume for small joints

13. Hyaluronic Derivatives Hylan G-F 20 (Synvisc) Systematic review suggests efficacy Cochrane review of 76 trials 40 vs placebo 6 vs NSAIDs 10 vs steroids Median quality About as good as steroids Cochrane Library 2006 Issue 2:CD005328

14. Hyaluronic Costs Euflexxa 20 mg/2 mL $139.20, repeated weekly for 3 weeks Hyalgan 20 mg/2 mL $138.94, repeated weekly for 3- 5 weeks, also available in 2 mL vials Orthovisc 30 mg/2 mL $123.90, repeated weekly for 3-4 weeks Synvisc 16 mg/2 mL $233.08, repeated weekly for 3 weeks Supartz 25 mg/2.5 mL $120.70, repeated weekly for 3-5 weeks

15. Steroid Costs Methylprednisolone acetate 20-80 mg as generic $1.40, Depo-Medrol $1.61 Triamcinolone acetonide (Kenalog) 20- 80 mg $1.39 Triamcinolone diacetate (Aristocort Forte) 20-80 mg $1.44 Triamcinolone hexacetonide (Aristospan Intra-articular) 20-80 mg $1.26 The Medical Letter 2006The Medical Letter 2006 Mar 27;48(1231):25

16. Tests to Consider If there is warmth, painful effusion, marked pain with range of motion, exquisite tenderness consider infections Blood work- ESR, glucose, protein Joint Fluid Cell count and differential Glucose and protein Cultures Gram stain Crystal analysis

17. Complications Caused by injection Bleeding (rare) Infection (1 in 10,000) Joint injury (incidence unknown): Avoid by aspirating slowly and not moving needle side to side in joint

18. Complications Caused by corticosteroid agent Acceleration of septic joint Subcutaneous fat atrophy (<1%), particularly if injection is <5 mm beneath skin surface Fistulous tract formation Steroid flare with pain 6 to 12 hr after injection (2% to 5%) Exacerbation of diabetes (rare) Osteoporosis (high doses over long period) Cartilage damage, particularly in weight-bearing joints

19. Complications Caused by corticosteroid agents Tendon rupture (<1%) Facial flushing (<1%) Transient paresis of injected extremity (rare) Asymptomatic pericapsular calcification (43%) Adverse gastrointestinal effects Mood alterations Fluid retention Menstrual irregularities Allergic or hypersensitivity reactions

20. Techniques Knee Lateral mid patella approach preferred Most likely to hit the joint Study of 80 patients injected 3 separate times by same physician Knee Extended J Bone Joint Surg Am 2002 Sep;84-A(9):1522

21. Techniques Knee Need the following Large syringe for aspiration Second syringe with medications Up to 10 ml total volume 22 gauge needle 1.5 inches long Alcohol wipes Betadine wipes Bandage

22. Techniques Ankle Foot

23. Techniques Ankle I Medication total volume should not exceed about 7 ml Palpate the junction of the fibula and the tibia just superior to the talus Palpate this soft triangular space Advance needle into space If bone encountered redirect medial and superiorly

24. Techniques Ankle II The space between anterior border of the medial malleolus The medial border of the tibialis anterior tendon Palpates this space for the articulation of the talus and tibia. Direct the needle postero-laterally

25. Techniques Ankle Foot

26. Techniques Tarsal Tunnel Caused by compression of posterior tibial nerve Tunnel is formed by medial malleolus and fibrous flexor retinaculum Chief complaint is burning sensation over the medial 1/3 of the foot Look for Tinel’s sign

27. Techniques Tarsal Tunnel Medication volume should not exceed 3 ml Needle is inserted 2 cm proximal to the identified location Angle is 30 degrees to the foot Tunnel is very superficial Aspirate prior to injection to make sure not in a vessel

28. Techniques Tarsal Tunnel Patient in lateral position with affected foot on bed Find positive Tinel’s sign Identify the posterior tibial tendon Patient inverts foot against resistant Nerve lies behind the tendon

29. Techniques Ankle Foot

30. Techniques 1 st MTP Joint Total volume should not exceed 2 ml Roughly 1 ml Lidocaine Roughly 0.25-0.5 ml Celestone May be difficult to palpate this joint Distraction helps open the joint Insert from medial approach Angle 60-70 degrees to conform to joint angles

31. General References Zuber TJ. Knee join aspiration and injection. American Family Physician 2002 Oct 15;66(8):1497-500, 1503-4, 1507 Rifat SF, Moeller JL. Basics of joint injection: general techniques and tips for safe, effective use. Postgraduate Medicine 2001;109(1):157- 166 Rifat SF, Moeller JL. Site-specific techniques of joint injection: useful additions to your treatment repertoire. Postgraduate Medicine 2001;109(3):123-36