Aspiration, Intra-articular and Soft Tissue Injections. MR KEWAL SINGH, MS(orth), FRCS(Eng)

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1 Aspiration, Intra-articular and Soft Tissue Injections MR KEWAL SINGH, MS(orth), FRCS(Eng)

2 Indications for Aspiration Haemarthrosis Septic arthritis Symptomatic relief of a large effusion Crystal-induced arthropathy Unexplained joint effusion

4 Indications for articular and periarticular injections Pain Trigger finger

5 Common conditions Inflammatory joint disease, e.g. Rh A, Gout, Pseudo gout etc Osteoarthrosis. Tenosynovitis, e.g. De Quervain s, Trigger finger. Tendinopathies, e.g. Tendo achilles, Rotator Cuff. Bursitis, e.g. Subacromial and trochanteric. Enthesopathies, e.g. Tennis and Golfer s elbow. Compression neuropathies, e.g. Carpal Tunnel Syndrome.

6 Contraindications to joint aspiration or injection Bacteremia Clinician unfamiliar with anatomy of or approach to the joint Inaccessible joints Overlying infection in the soft tissues Severe coagulopathy Severe overlying dermatitis Uncooperative patient

7 Common sites for injection Knees. ( Joint, ligaments and tendons around the joint). Shoulders. (Subacromial space, Acromio-clavicular joint, Glenohumeral joint). Elbow. (Tennis and golfer elbow, joint). Wrist. (CTS, Dequervain s, Tendinopathies, OA, Trigger finger, Tendons). Thumb. (CMC joint). Hip. (Joint, Trochanteric bursitis). Foot & Ankle ( Joint, Plantar fascitis).

8 Shoulder joint

9 Shoulder From front From back Frome side Subacromial space

10 Shoulder From front From back Glenohumeral joint

11 From top ACJ Shoulder Acromioclavicular joint

12 Injection for tennis elbow Elbow

13 Elbow joint

14 Wrist Areas for injection into carpal tunnel

15 Stenosing tenosynovitis (De Quervain s disease)

16 MCP joint

17 CMC Joint thumb

18 Trigger finger

19 Knee joint

20 Knee joint From medial or lateral side of patelofemoral joint

21 Hip

22 MTP joint

23 Ankle joint

24 Ankle joint Tendo achilles Subtalar joint Midtarasal joint Plantar fascitis

25 Role of Injections Therapeutic: Anti-inflammatory effect. Diagnostic: Local anaesthetic effect. Aspiration of the joint.

26 Common agents in use Steroids. Triamcinolone acetonide. Methyl prednisolone acetate. Local anaesthetics. Lignocaine 1-2%. Bupivicaine %. Combined preparations of steroids and LA. Viscosupplements. Saline. Radioisotopes. Infliximab

27 Actions of steroids Suppress inflammatory process. Reduce vasodilatation. Decrease release of chemical mediators of inflammation (kinins, destructive enzymes and prostaglandins).

28 Action viscosupplements Physical cushioning. Stimulates synoviocytes to synthesize synovial fluid. Anti-inflammatory effect.

29 Complications Transient increase in pain (most common) Occurs in approximately 5% of patients. Subsides within 24 hours. May be caused by the less soluble steroids. Skin and subcutaneous tissue atrophy. Depigmentation. Tendon rupture. Adrenal suppression (when given more than 1 to 2 times per month). May interfere with lactation in nursing mothers. Infection occurs in 1 in 10,000 patients.

30 EQUIPMENT Sterile Tray for the Procedure Sterile gloves Sterile fenestrated drape 2 10-mL syringes 2 21-gauge, 1-inch needles 1 inch of 4 4 gauze soaked with povidone-iodine solution (Betadine) Hemostat (for stabilizing the needle when exchanging the medication syringe for the aspiration syringe) Sterile bandage

31 Indications Osteoarthrosis and inflammatory arthritis. Tendonosis. Tenosynovitis. Bursitis. Carpal Tunnel Syndrome. Trigger points.

32 Technique Clean environment. Two needle technique. Often helpful to anaesthetise the injection area with a small needle. One needle technique.

33 Technique Don t rush Aspirate any fluid in the joint to improve pain relief Large joints: a 10-cc combination of lignocaine and steroid Small joints: 1 cc to 5 cc combination of lignocaine and steroid Combine short (Lignocaine) and long (Bupivicaine) acting local anaesthetics with steroid to provide pain relief for longer period.

34 Efficacy Steroid injections are more effective in inflammatory joints than OA. Viscosupplements are effective in OA for only short duration.

35 Caution! Repeated injections of steroids cause damage to the joints, tendons & ligaments. Usual gap about 8 weeks. Not more than 3 injections.

36 Further reading 1. Creamer P. Intra-articular corticosteroid treatment in osteoarthritis.curr Opin Rheumatol.1999;11(5): Gaffney K, Ledingham J, Perry JD. Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response.ann Rheum Dis.1995;54: Ike R. Therapeutic injection of joints and soft tissues. In:Primer on the Rheumatic Disorders.Atlanta, Ga: Arthritis Foundation; Speed C A, Corticosteroid injections in tendon lesions. BMJ, Vol Aug 2001; Kumar N, Complications of intra-and peri-articular sterois injections.br. J. Gen. Pract. June 1999; Gromley G J, A randomised study of two training programmes for the GPs in the technique of shoulder injections. Ann Rheum Dis 2003; 62:

37 Any?s

38 Thanks!

Professor Lisa Stamp

Professor Lisa Stamp Rheumatologist University of Otago, Christchurch 8:30-9:25 WS #65: Joint Injection Techniques 9:35-10:30 WS #75: Joint Injection Techniques (Repeated) Joint/soft tissue corticosteroid