Lower Extremity Workshop

Gil C. Grimes, MDFebruary 22nd 2007

Objectives

Indications for aspiration and injections

Contraindications to aspiration Contraindications to injection Medications Tests to consider Adverse reactions and complications Techniques

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

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

Contraindications for Injections

Adjacent osteomyelitis Bacteremia Hemarthrosis Impending (scheduled within days)

joint replacement surgery Infectious arthritis

Contraindications for Injections

Joint prosthesis Osteochondral fracture Periarticular cellulitis Poorly controlled diabetes mellitus Uncontrolled bleeding disorder or

coagulopathy Failure to improve with prior

injections

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

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

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

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

Steroid AgentsAgent Relative anti-

inflammatory potency

Relative mineralocorticoid potency

Solubility

Hydrocortisone acetate 1 2-3 High

Prednisolone tebutate 4 1 Medium

Methylprednisolone acetate 5 0 Medium

Triamcinolone acetonide Triamcinolone diacetate Triamcinolone hexacetonide

5 0 Medium

Betamethasone sodium phosphate and acetate

20-30 0 Low

Dexamethasone acetate and sodium phosphate

20-30 0 Low

Anesthetic Agents

Use higher concentration smaller volume for small joints

Drug Onset of action Duration of action Maximum volume

Lidocaine HCl

1% 1-2 min ~1 hr 20 mL

2% 1-2 min ~1 hr 10 mL

Bupivacaine HCl

0.25% 30 min 8 hr 60 mL

0.5% 30 min 8 hr 30 mL

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

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

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 2006 Mar 27;48(1231):25

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

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

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

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

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 ExtendedJ Bone Joint Surg Am 2002 Sep;84-A(9):1522

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

Techniques Ankle Foot

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

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

Techniques Ankle Foot

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

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

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

Techniques Ankle Foot

Techniques 1st 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

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