Apply Evidence Based Medicine to Arthrocentesis

Skills:Shoulder and Knee

Gregory C. Gardner, MD, FACPGilliland-Henderson Professor of

MedicineUniversity of Washington, Seattle, WA

Evidence Based References

Evidence based references Courtney and Doherty. Best Practice & Research Clinical

Rheumatology 2009; 23:161–192 (2013 update) Crawshaw DP et al. Exercise therapy after corticosteroid

injection for moderate to severe shoulder pain. BMJ 2010;340:c3037 doi:10.1136/bmj.c3037

Raynauld JP, et al. Safety and efficacy of long-term intraarticular steroid injections for osteoarthritis of the knee. Arthritis Rheum 2003;48:370-377

Habib GS, et al. Local effectes of intra-articular corticosteroids. Clin Rheumatol 2010;29:347-356

Gardner GC. Teaching arthrocentesis and injection techniques: what is the best way to get our point across. J Rheumatol 2007 vol. 34 (7) pp. 1448-1450

Outline of Workshop

Didactics

Procedure pearls

Anatomy review

Clinical Issues and technique review

Surface anatomy

Present evidence based best practices

Current status of how we do and teacharthrocentesis and injection therapy

Dangers of “Evidence based

Medicine”

Analytic rubric Procedure distilled into discrete steps:

1. Patient counseling

1. Discuss reasons for doing

the procedure

2. Discuss details of doing

the procedure

3. Discuss potential side

effects

4. Inquire about potential

contra-indications

2. Patient preparation

5. Able to verbalize anatomy

and mark appropriate

location

6. Patient positioned properly

for site of procedure

7. Skin cleansed properly

8. Appropriate application of

anesthesia

Analytic rubric continued

3. Needle insertion

9. Choose appropriate

needle and syringe for

procedure

10. Needle inserted at

appropriate angle/depth

11. Needle/syringe stabilized

during procedure

12. Aseptic technique

4. Post-procedure wrap-up

13. Skin re-cleansed if

necessary, site bandaged

14. Post-procedure counseling

provided

15. Sharps disposed of

properly

16. Operator showed concern

for patient comfort

Utility of Rubric

Framework for teaching arthrocentesis skills

Can be used to think about and applying evidenced-

based principles

Useful as assessment tool for physicians in training

Useful as a documentation of procedure competency

Procedure Pearls

Textbook complications of arthrocentesis & injection therapy; How much should we worry?

Textbook complications of arthrocentesis & injection therapy; How much should we worry?

Charcot arthropathy – very rare; why would it develop and how often can we safely inject an joint?

Periarticular calcifications – 4% give or take may develop Infection – very rare (TBD) Post-injection synovitis – uncommon; 6-12 hrs following

procedure and resolves in 48 hrs Tendon rupture – rare; avoid injecting tendon especially high

tension tendons i.e. Achilles Skin depigmentation – 5%; may develop 8 wks after injection

and resolve by 16 wks Subcutaneous fat atrophy – up to 8%; avoid placing

corticosteroid in subcutaneous fat Other – AVN, hyperglycemia, flushing

Textbook contraindications to injecting corticosteroids into joints and soft tissue

Textbook contraindications to injecting corticosteroids into joints and soft tissue

Infection or suspected infection around the joint Avoid injecting through psoriatic plaque

Hypersensitivity to injectables Most “hypersensitivity” is to epinephrine; no need to

use

Upcoming surgery on the joint TBD

Suspected intra-articular fracture/joint instability Anticoagulation

Caution not contraindication; TBD

Joint procedures and infection

Seror et al Rheumatology 1999 Retrospective study involving 69 French

rheumatologists Mean number of years in practice 20.9 Mean number of corticosteroid injections per year 809 Total injections 1,160,000 in 20 years with 15

instances of post injection infection Overall rate of infection was 1/77,300

When pre-packaged CS syringes used: 1/162,000 When multi-dose vial used: 1/21,000 (7.7 X higher!)

1/4.6 rheumatologists had post-injection septic complication over 20 years

How often can we inject a knee?

68 knee OA pts randomized to either saline or 40 mg of triamcinolone acetate injections every 3 months for 2 years

Double blind study After 2 years of therapy, no difference in joint

space width between groups (figure) Joint pain at night and stiffness significantly better

for steroid group using AUC analysis at 2 years Conclusion:

JS not affected Clinical improvement especially

at 1 year, less apparent at 2 yrs No significant SE

Raynauld et al. Arthritis Rheum 2003;48:370

Steroid injection into hip prior to THAChitre et al. JBJS 2007

99 pts had received steroid/local anesthetic into hip joint 4 to 50 mo prior to THA; mean 18 mo

Follow-up 25.8 mo post-surgery with range 9-78 mo

NO instances of post-operative joint infection or sepsis occurred

Similar data from Sankar et al and Sreekumar et al in the hip and Desai et al in the knee

Data from McIntosh et al raise concern about infection if given within 6 weeks of surgery (trend but NS)

McIntosh et al. Clin Orthop Relat Res 2006

Best way of cleansing the skin?

Current evidence based guidelines for inserting IV catheters suggests the following is best practice according to EPIC 2, a mega- systematic review of best practices for prevention of catheter associated infections Decontaminate the skin site with a single patient use

application of alcoholic chlorhexidine gluconate solution (preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol) prior to the insertion of a central venous access device. (Class A)

Use a single patient use application of alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter (Class D)

Journal of Hospital Infection (2007) 65S, S1–S64

Arthrocentesis and anticoagulation?Ahmed and Gertner Am J Med 2012

Retrospective review of complication in 640 arthrocentesis in 514 anticoagulated patients

Compared the incidence of significant bleeding in patients by INR (>2 or < 2)

Conclusion: no need to reduce anticoagulation level prior to procedures

Complication

INR >2N=456

INR < 2N=184

Early Bleeding

1 (0.2%) 0

Late Bleeding 0 0

Infection 1 (0.2%) 0

Pain 3 (0.7%) 0

Comparisons between groups NSPatient with bleeding also had pain

Should I use anesthesia prior to a procedure?

Park et al Rheumatol International 2009 99 patients underwent 2 arthrocenteses

One without and one with anesthesia Procedures performed with:

Conventional syringe or Reciprocating procedure device

Pain measured on 10 cm VAS (0 no pain; 10 unbearable pain)

Conventional syringe Reciprocating syringe P

# of subjects 49 50

Pain w/o anesthesia 9.22 9.39 NS

Pain of anesthesia 6.18 3.96 .006

Pain after anesthesia 4.10 1.84 .003

% Pt wanting anesthesia

100% 100% NA

Benefit of buffering lidocaine Lidocaine maintained at acidic pH to increase shelf life; pH 6.2 preventing

photodegradation/aldehyde formation; lidocaine-epinephrine has even lower pH (5.98) Sodium bicarbonate neutralizes pH (7.2) but does not affect onset of action; increases efficacy

via increasing uncharged form of drug Buffering: 1 part (1mEq/ml) sodium bicarbonate to 10 parts lidocaine Consistent literature favoring buffering:

Vasectomy Bone marrow Bx IV cannula insertion Laceration repair Etc..

Cristoph et al. Ann Emerg Med 1988;17:117-120

Pain scores on VAS following intradermal infiltration of unbuffered and buffered local anesthesia

Cristoph et al. Ann Emerg Med 1988;17:117-120pH noted

Pain

on

VA

S

6.21

7.22

5.98

7.16

6.18

7.20

Needles: Primum non nocere or Gardner’s rule 23 “use the smallest needle necessary to get the job done”

18 Gauge18 Gauge18 Gauge18 Gauge

18 gauge in articular cartilage18 gauge in articular cartilage

25 Gauge25 Gauge25 Gauge25 Gauge

22 Gauge22 Gauge22 Gauge22 Gauge

John Clark, MD, PhD

Three Way Stop CockSimkin Method

New ways of doing procedures

Reciprocating Procedure Device

Dual Injector

Which is he best corticosteroid preparation?Which is he best corticosteroid preparation?

Triamcinolone (Aristospan, Kenalog) - easily goes through 26-30 gauge needles,

Methylprednisone Acetate (Depomedrol) - floculant, may require larger than 30 gauge needle.

Betamethasone Acetate (Celestone Soluspan) - mixture of short and long acting preparation

Dexamethasone Acetate (Decadron-LA) - Long acting, frequently mixed with Decadron for short and long acting combination

Only head to head trial of TCA 20 mg vs MPA 40 mg in knee OA - TCA better pain relief, MPA lasted longer

In 2 small trials of TCA vs MPA in RA, TCA lasted longer

Pyne D, et al Clin Rheumatol 2004;23:116-120

Can we mix anesthetic and steroids?

Dogma about not “mixing” local anesthetic with steroids especially methylprednisolone; 74% of us do mix

Preservative parabens may cause steroid to appear flocculant

HPLC study to determine stability of mixed contents for epidural injections

Conclusion: mix away!

Formula 1

TriamcinoloneBupivicai

neIohexol

4 hours 93% 101 103

24 hours 97 99 101

Formula 2

TriamcinoloneLidocain

eIohexol

4 hours 85 101 91

24 hours 85 101 97

Formula 3

Methylprednisolone

Bupivicaine

Iohexol

4 hours 88 103 104

24 hours 86 103 98

Formula 4

Methylprednisolone

Lidocaine

Iohexol

4 hours 101 102 98

24 hours 98 99 93

Percent drug remaining after time noted by HPLC

Stored at 370Shat et al. BJ Radiology 2009;82:109-111

Why do patients with acute onset joint effusions keep their joint at 30-450 of flexion? Boyles Law of course!

www.grc.nasa.gov/WWW/K-12/airplane/aboyle.html

Boyles Law: Pressure is inversely proportional to volume when temperature is constant in a closed system pV=C

Joint position and intra-articular pressure:Maximum joint volume between 30-450 of flexion

Hochberg et al. Rheumatology 3rd edition

Practice Point:Three causes of severe joint pain

There are three causes of joint pain so severe that the patient will guard the joint and protect against movement BUGS BLOOD CRYSTALS

Patients hold their joint 300 of flexion as this represents maximum joint volume; flexion or extension results in reduced volume thus increased pressure

Slowly developing joint effusions allow time for the capsule to distend and thus do not cause the same degree of pain

BBC Joint

RadiusUlna

Radius Ulna

DirectionDirectionof Needleof NeedleDirectionDirectionof Needleof Needle

Convex vs Concave Joint SurfacesConvex vs Concave Joint Surfaces

Electronic Textbook of Hand Surgery www.eatonhand.comElectronic Textbook of Hand Surgery www.eatonhand.com

Concave

Carpus

Convex

Making your own polarizing microscope

Synovial Fluid Findings

Only a small amountOnly a small amount

of synovial fluid is of synovial fluid is

necessary to makenecessary to make

the diagnosis of the diagnosis of

crystalline forms ofcrystalline forms of

arthritis; important arthritis; important

to crystal prove at to crystal prove at

least onceleast once

Scope and Kit

Placing Polarizer and Analyzer

Crystals

Shoulder

Subacromial Region

Shoulder Anatomy

Osseous structures Scapula Scapular spine Acromium Glenoid Coracoid Clavicle Humerus

Shoulder Anatomy

Important muscles Deltoid Rotator Cuff Scapular stabilizers

Important joints Glenohumeral Acromioclavivular “Scapulothoracic”

Other Redundant capsule Subdeltoid bursa

Glenohumeral Joint: Circle of Stability

Note pear shaped glenoid that allows humeral head to be depressed by RTC

muscles

Long head of biceps tendon

Shoulder Joint Capsule

Grays Anatomy

Capsule distended

Mike Richardson, M.D.Mike Richardson, M.D.

External rotation view

Axillary view

Suggested X-rays:Suggested X-rays:

Internal rotationInternal rotation

External rotationExternal rotation

Axillary viewAxillary view

Dx in 101 Patients with Shoulder Pain Over 18 Months in Internal Medicine Clinic

Diagnosis Percent

Rotator Cuff Disease 62

Myofascial Pain 22

Adhesive Capsulitis 10

AC Joint OA 4

Bicepital Tendonitis 3

RA/OA/RSD/PMR 1 each

Anderson, Kaye. West J Med 1983; 138:268

Impingement Syndrome Impingement is caused by compression of the

rotator cuff tendons and subacromial bursa between the greater tubercule of the humerus and the lateral edge of acromion; direct trauma vs impairment of blood supply?

3 stages of impingement syndrome described by Neer Stage 1 - Edema and hemorrhage

Stage 2 - Cuff fibrosis, thickening, and partial cuff tearing

Stage 3 - Full thickness tendon tears, bony changes, and tendon rupture.

Neer CS, 2d. Impingement lesions. Clin Orthop 1983; 173:70

Posterolateral Injection of the Subacromial Space

Posterolateral Injection of the Subacromial Space

Behind humeral head,

under the acromium,

directed toward the AC joint

25 gauge, 1 1/2 inch needle

Anesthesia with 3-4 cc 1-2%

lidocaine useful as

diagnostic test

Inject with 2 cc bupivicaine

& 20-40 mg of depomedrol

or triamcinalone

Lateral Subacromial Injection

Lateral

Palpate AC joint

Identify acromion

1 cm below

acromion; angle

under AC joint

Subacromial Injection: Lateral vs Posterolateral

Note how patient is elevating arm?

Injection + exercise vs exercise alone for RTC tendonitis

227 pts randomized to injection + exercise vs exercise alone for impingement syndrome; mean 16 wks of pain

20 mg of triamcinolone plus lignocaine Exercise individualized; attended as many PT sessions as

necessary Outcome:

1 & 6 wks pain/disability scores significantly better for injection

At 12 & 24 wks NO difference between groups At later assessments, exercise only group taking more pain

meds & 32% were injected at some time between 12 and 52 wks

Conclusion: Injection therapy provides early pain improvement in

impingement syndrome One-third of exercise only patients go on to injection

Crawshaw et al BMJ 2010

Do repeated injections lead to RTC tears?

230 patients who had had an MRI scan for impingement symptoms retrospectively evaluated for frequency of RTC tears by number of subacromial steroid injections

128 had 0-2 injections, 102 had 3 or more Exclusions: age > 70, trauma, RA, Diabetes Results:

Conclusion: repeated injections NOT associated with RTC tears More full thickness tears in fewer injection group??

0-2 injections 3 or more

RTC tears 65 (50.8%) 48 (47%)

Partial thickness

12 21

Full thickness 50 24

Massive tear 3 3

Ann R Coll Surg Engl 2009; 91: 414–416

Does a corticosteroid injection help in adhesive capsulitis and if so does it matter where we put it?

191 pts with adhesive capsulitis randomized to 4 groups; all received progressive PT1. Subacromial steroid injection (40 mg TCA)2. Glenohumeral steroid injection3. Combination injection using same total steroid

dose4. NSAID

At 16 weeks steroid groups significantly less pain and improved motion compared to NSAID only

At 24 weeks no difference b/w groups Did not matter where the steroid was placed (US

guided)

Shin SJ, Lee SY. J Shoulder Elbow Surg 2013;22:521-527

Knee

Knee anatomy

Important points:

Synovial space extends

above patella; large target

Synovial space posterior

to knee joint as well; may

explain why patients have

posterior pain with an

effusion

Gray’s Anatomy

ACL PCLACL PCL

Infrapatellar Fat Pad

BursaeBursae

MenisciMenisci

MenisciMenisciJoint Joint

CapsuleCapsule

Shape of PatellaShape of PatellaPatellaPatella

, , LateralLateral

PatellaPatella, ,

LateralLateral

Patellar GroovePatellar Groove(Femoral Sulcus)(Femoral Sulcus) Patellar GroovePatellar Groove(Femoral Sulcus)(Femoral Sulcus)

Femoral Femoral CondylesCondylesFemoral Femoral CondylesCondyles

MultiMedia Group, used with permissionMultiMedia Group, used with permissionMultiMedia Group, used with permissionMultiMedia Group, used with permission

Axial View of KneeAxial View of KneeVisible HumanVisible Human

Axial View of KneeAxial View of KneeVisible HumanVisible Human

Note Note ““keelkeel”” of the patella of the patellaPurpose of patella?Purpose of patella?

Lateral

Medial

Suprapatella

Lateral

Medial

Lateral

Medial

Lateral

Medial

Lateral

Medial

Midpatella

Lateral

Medial

Lateral

Medial

Reasons to aspirate or inject a knee Aspirate

Confirm inflammatory arthritis/crystalline arthritis R/O septic arthritis (knee most affected joint) Relieve pressure in OA/inflammatory arthritis

Inject Treat inflammatory arthritis with IA steroids Inject steroids/hyaluronic acid for OA

Equipment 21-22 gauge needle for aspiration (18??) 25 gauge to inject only 20-40 mg of triamcinolone or depomedrol Like celestone soluspan for gouty arthritis when available

Knee approaches

There are at least 4 different routes utilized to enter the knee joint Medial mid-patellar Lateral supra-patellar Anteromedial or anterolateral Lateral mid-patellar

Each route has their proponents but it is important to be be familiar with several as some patients will not be easily approached via your most comfortable route

Medial knee approach

Medial approach is particularly useful when there is a small effusion

Identify the superior and inferior poles of the patella

Mark a location 1/3-1/2 down from the superior pole and just below the medial margin of the patella

Angle needle slightly inferior and a bit superior to miss the patellar keel

Make sure you look at the patient’s foot; the needle should be generally perpendicular to the foot

Courtney & Doherty: Best Practice & Research Clinical Rheumatology. 2009

Superolateral knee approach

This approach is useful for large effusions

Mark the area where the superior and lateral margins of the patella meet

Angle the needle down and medially into the joint space

Courtney & Doherty: Best Practice & Research Clinical Rheumatology. 2009

PatellaPatella

Medial Medial edge of edge of patellar patellar

ligament ligament Tibial Tibial

plateauplateau

This approach can be done from either the medial or lateral surface

Identify the patellar ligament then the tibial plateau

Generally there is a “soft spot” that identifies the area adjacent to the ligament and just above the tibial plateau

Angle the needle toward the center of the knee

Anterior approachesfor knee injections

Anterior approach

“Soft spot” Needle directed toward center of knee Not recommended for aspiration

Lateral Midpatellar Approach Remember MRI scan Suggest inserting

needle no further than 1/2 the way down the lateral patellar margin

Tissue to traverse is thin laterally and can use 1” needle in normal sized person

John Clark is using butterfly needle in this picture

John Clark MD, PhD

Bilateral knee effusions

Note loss of medial concavity and bulging suprapatellar pouchNote loss of medial concavity and bulging suprapatellar pouchNote loss of medial concavity and bulging suprapatellar pouchNote loss of medial concavity and bulging suprapatellar pouch

Anesthesia with 1-2% lidocaine without epinephrine(what is wrong with this picture?)

Note marks on kneeNote marks on knee

Aspiration with 21-22 gauge needle and 20-30 cc syringe

Using mosquito clamp to change from aspiration to injection syringe

Injecting with 40 mg of triamcinolone or depomedrol +/- mixed with small amount of local

anesthetic

Clean, bandage, bed rest x 24 hr

Accuracy of knee injection into non-effused joints by location of injection

240 knee injected for OA done by one orthopaedic surgeon into knees without effusions

Three approaches; anteromedial, anterolateral, and lateral mid-patellar

Placement of injected material confirmed by fluoroscopy

Accuracy: Anteromedial: 60/80 in joint space (75% accuracy) Anterolateral: 57/80 in joint space (71% accuracy) Lateral mid-patellar: 74/80 in joint space (93% accuracy)

Jackson et al. JBJS 2002;84-A:1522-27

Aspirate or not aspirate RA knee before steroid injection? 191 swollen RA knees randomized to receive 20

mg of triamcinolone following: Complete aspiration of fluid No aspiration of fluid

Followed 6 mo primary end point recurrent knee swelling

Groups balanced with regard to gender, medications, prednisone use, ESR etc.

Primary end point: Relapses in 23% of aspirated knees Relapses in 47% of non-aspirated knees (p = .001)

Medications changed in similar % of pts during study period

Weitoft & Uddenfeldt. Ann Rheum Dis 2000; 59:233

Should an RA knee be rested following injection?

Old dogma: bed for 2-3 days and then use crutches for 2-3 wks

Chakravarty et al Br J Rheum 1994 Randomized 91 Pts with inflammatory knee arthritis to 24 hr

of in hospital rest or usual activity after 40 mg of triamcinolone hexacetonide & 2 cc of lignocaine in knees aspirated to dryness

VAS pain, knee circumference, 50 foot walk time, CRP followed at 3, 6, 12 and 24 months

Results - both improved at 3 wks; RG showedhighly significant improvement through 24 wks compared to NRG in all of the study variables;8 NRG & 2 RG Pts required reinjection

Conclusion - 24 hr of bed rest improves clinical outcome for inflammatoryarthritis patients (OA pts as well?)

Conclusion Make sure our patients are well informed about the procedure process

If unsure, review basic anatomy before procedure

Be careful but remember that serious adverse events are very rare

Evidence based approach will hopefully turn a “wild west” approach to arthrocentesis and injection into a more orderly process!