The right medicine, in the right quantity, in the right place, at the right time.

Transcription

1 Ian Reilly FCPodS DMS Consultant Podiatric Surgeon Injection therapy (IT) for the treatment of joint pain has been performed for many years using different substances Compounds such as sodium bicarbonate, potassium phosphate and procaine have been used from the first half of the twentieth century Miller JH, White J, Norton TH. The value of intra-articular injections in osteoarthritis of the knee. Journal of Bone and Joint Surgery 1958; 40B: ) Hollander et al reported the use of hydrocortisone and cortisone in 1951 with further reports produced by Bornstein and Fallet, and Lambelet(cited by Miller et al) Hollander JL, Brown EM Jr, Jessar R, Brown C. Hydrocortisone and cortisone injected into arthritic joints; comparative effects of and use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc. 1951; 147: Even though injectable steroids have been around for more than 50 years, there is a paucity of (good) evidence regarding their use The challenge is to apply what evidence is available appropriately in a safe and effective manner Hyaluronate, alcohol, prolotherapy, needling The right medicine, in the right quantity, in the right place, at the right time. David Lannik MD, 2005.

2 Diagnostic value Pain relief Aspiration Therapeutic value Definitive treatment To provide a pain-free window for some other (curative) therapy) To provide episodic pain and symptom relief Improve mobility Improve function Reduce pain Intra-articular Peri-articular First, Do No Harm Soft tissue (ST)

3 Chemically, they are derived from cholesterol and all the molecules share a common chemical structure Physiologically, the glucocorticoids have a wide range of actions as glucocorticoid receptors are found in a wide range of tissues As well as anti-inflammatory and immunosuppressive actions, they affect carbohydrate, protein and lipid metabolism, the cardiovascular and the central nervous systems Corticosteroids are injected locally for an anti-inflammatory effect Cell Injury Leukotrienes Prostaglandins Phospholipids Arachidonic Acid COX I/II Endoperoxides Thromboxane A2 Phospholipase A 2 Steroids NSAIDs Prostacyclins Triamcinolone acetonide Adcortyl 10mg/ml Kenalog 40mg/ml Net price 1ml vial = 1.49 Methylprednisolone acetate Depo-Medrone 40mg/ml Net price 1ml = 2.87 (also 2/3mL) Net price with lidocaine = 3.28 Betamethasone phosphate Betnesol 4mg/ml Net price 1ml amp = 1.17 Hydrocortisone acetate Hydrocortistab 25mg/ml Net price 1ml amp = 5.72 Diagnostic Therapeutic? Both? Explain to your patient in advance of the possible outcomes and your subsequent strategy Plantar fasciitis Morton's neuroma Hallux limitus

4 Diagnosis Injections will not benefit everyone! Knowledge of anatomy Treatment algorithms Technique Drug choice Dosage Diagnosis An inaccurate diagnosis is made Knowledge of anatomy The drug is put into the wrong tissue Treatment algorithms Steroid therapy is used inappropriately Treatment is aimed at alleviating the symptoms without addressing the underlying cause Technique Poor technique allows the spread of drugs into adjacent tissues Injections are given too frequently Little regard is given to aftercare Drug choice An inappropriate drug is chosen Dosage Too little or too large a dose is given Soft tissue injection If the patient is pregnant or breastfeeding Overlying soft tissue infection, cellulitis or dermatitis A viral infection or TB Bacteremia A known hypersensitivity to any of the constituent agent Lack of response after two injections Severe coagulopathy Anticoagulant therapy (relative contraindication) Intra-articular injections As for soft tissue, and: No more than 3 injections per year in weightbearingjoint Unstable joints Inaccessible joints Joint prosthesis Osteochondral fracture 1. Select the patient 2. Prepare the injection site 3. Prepare the injection 4. Give the injection 5. Record drugs/dose/batch No s 6. Give aftercare advice

5 Do you have a clear diagnosis? Is injection therapy the best treatment? at this point in the treatment pathway Discuss all the options Are there any contraindications? absolute or relative Warn about side effects Record that this has been done Information to be given to the patient should include: The diagnosis and nature of their condition The details of proposed treatment and the alternatives The nature and effects of drugs to be given The most likely possible side effects and incidence The likely benefits Your plans for follow-up and after care Mark the site Position the patient Mark the site Swab the skin and allow to dry Iodine for joint injections Cotton wool and plaster at hand MARK A CROSS CLEANSE THE CENTRE Decide the dose and volume Wash and dry hands Open vials/swab bungs Draw up the steroid Dilute with local anesthetic: 50/50, depending on local guidelines Change the needle after drawing up solution(s) Hand washing and skin disinfection is important do it in front of the patient Simon AC (2004) Hand hygiene, the crusade of the infection control specialist. Alcohol-based handrub: the solution! : Acta Clin Belg Jul-Aug;59(4):

6 White Green Blue Orange Grey 19g 21g 23g 25g 27g

7 Clinician preference (strength/dose) Soft tissue: Methylprednisolone Hydrocortisone Joints: Triamcinolone 40mg triamcinolone 40mg methylprednisolone 6mg betamethasone 4 mg dexamethasone Diagnosis Analgesia Dilution Distension Diagnosis: this helps confirm the placement of the solution and the diagnosis Analgesia: although temporary, a reduction in pain will make the whole process less painful for the patient, may help break the pain cycle and may reduce the post-injection flare Dilution: an increased volume of solution helps spread the active drug where a larger joint is being injected Distension: large volumes of injected solution may help break down adhesions Patient consent can be oral or written, but must be informed Use (non-sterile) gloves; gowns are not required Keep talking to the patient let them know what to expect Apply strong skin traction using a non-touch technique Insert the needle rapidly and perpendicularly to the skin Attempt to aspirate Inject joints and bursae as a bolus; entheses with a peppering technique Withdraw needle gently and keep the plunger depressed to prevent suction of the steroid back into the syringe Compress the site with cotton wool to prevent capillary leakage along the needle tract Dispose of sharps safely Apply a dressing

8 The injection can be painful we are often injecting into a hot spot (PMT) Be aware of patient apprehension Technique used Aseptic Drugs Name of drug Dose Batch number Expiry date Information sheet Warnings given You should try and rest for the first 2-3 days after the injection and avoid any activities that normally make your symptoms worse... Treatment... Surgery... Injection... Etc...!

9 Bugger! You will see complications! Use: 2.5 mlsyringe 23/25 g needle (to inject with) mg of methyl-pred or hydrocortisone Palpate the hot spot and mark Inject from a medial approach ( or plantar) Work the needle progressively deeper Look for needle paraesthesia and go gently Aspirate Inject peppering technique

10 Surgery Joint Injections Rx NSAIDs OTC NSAIDs Paracetamol Patient education, PT, OT, BMI, exercise, etc Creamer P et al, Lancet 1997;350: Difficulty Frequency Use: 2.5 ml syringe 21g needle (to draw up with) / 23/25g needle (to inject with) mg of triamcinolone (or methyl-prednisolone) Palpate the joint line Distract and plantarflexthe toe the joint line may pucker (if there minimal dorsal arthrosis) You may be able to palpate this Start dorso-medially (DM): insert the needle away from EHL Medial and dorso-lateral (DL) approaches can be tried if the DM approach is difficult If you do go DL, remember the EHB tendon Ensure you are in the joint (given the length of the needle) Remember the curvature of the joint: damage from the needle tip can aggravate the pain

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12 Use: 2.5 ml syringe 23/25 g needle (to inject with) mg of methyl-pred or hydrocortisone Palpate the IM space Mark up or visualise the MPJs Hold the needle lightly at 90 degrees to the skin Look for needle paraesthesia deep and go gently Inject in-between and distal to the MPJs Remember the plantar surface of the skin the patient may feel pin-prick sensation plantarly and falsely think this is from the neuroma (causing lipo-hypotrophy) Talk to the patient they may JUMP! 1. An accurate diagnosis 2. Good judgement 3. Technical skills As a basis, sound (3D) anatomical knowledge is crucial is just the beginning! "Education is a progressive discovery of our own ignorance." Will Durant Foot and Ankle Injection Techniques: A Practical Guide Stuart Metcalfe, Ian Reilly. 2010

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