Arthrocentesis and Joint Injection for the Internist

1. Arthrocentesis and Joint Injection for the Internist Suzanne Emil, MDRheumatology Fellow University of New Mexico

2. Overview • Indications for Aspiration or Injection • Choice of Glucocorticoid Preparation • Frequency of Injections • Techniques • Knee • Shoulder • Ankle • Wrist

3. Indications for Aspiration • Evaluation of any “unknown” joint effusion • Evaluation for septic arthritis • Initial confirmation of gouty arthritis • Aspiration to reduce the size of an effusion prior to injection of glucocorticoid • Improved outcome for patients with RA

4. Indications for Injection • Rheumatoid Arthritis, persistent activity in large or medium sized joints • May slow erosion • Other inflammatory arthritides, erosive or not. Particularly helpful if oligoarticular • Osteoarthritis of large weight bearing joint with bone on bone pain • Small joint osteoarthritis (CMC) • Subdeltoid bursitis or rotator cuff tendonitis

5. Relative Contraindications • Rheumatoid arthritis in small joints of the hand • Rheumatoid arthritis with one joint out of proportion to others—until infection ruled out • Monoarthritis with septic appearing joint, especially in diabetics • Early OA (cartilage repair may be important) • Small joint OA which failed to respond for 6 weeks to a prior injection • Subacute shoulder pain not responsive to a prior injection

6. Choice of Glucocorticoid Preparation • Generally prefer Triamcinolone for intra-articular (IA) injections (causes potent soft-tissue atrophy) • IA injection atrophies the pathologic synovial membrane (desired) • Extra-Articular injection atrophies fat, muscle, skin and ruptures tendons (undesired) • Generally prefer Methylprednisolone for tendon/bursa injections (less soft-tissue atrophy and complications, but less effective for joints)

7. Frequency of Injection • Typically limit to a maximum of 4 injections/year for any given joint • For OA with inevitable joint replacement, can perform palliative injections once every 3 months • But not within 4 months of a TJA (increased infection rate)

8. Complications • Infection, approximately 1/3500 procedures (at UNM less than 1/15,000 procedures) • Post-Injection Flare • <48hours, but may last up to 72 hours • Flushing-Anxiety, Sleeplessness Reaction • 10% of patients receiving triamcinolone acetonide • Leakage of joint fluid • More common with drainage of popliteal cyst, incomplete drainage, anticoagulants, and drainage of effusion using >22g needle, also common in infected (septic) joint (fistula formation) • Steroid atrophy (subcutaneous fat, skin, muscles, tendons) • Skin hypopigmentation • Tendon rupture • RA, biceps tendon, rotator cuff injections (more common with posterior injections), achilles tendon • Prior use of fluoroquinolones

9. Complications Skin Hyperpigmentation Steroid Skin Atrophy

10. General Considerations • 1 step technique • 1 needle, syringe (lidocaine and corticosteroid are mixed)After antisepsis, with appropriate needle, quick, sure puncture through skin and joint capsule precludes need for local skin anesthesia • Benefits: • 1 stick • Disadvantages • Preservatives in lidocaine may decrease sensitivity of synovial fluid culture if lidocaine contaminates a SMALL culture sample • More painful if readjustment of needle required (frequent) • Patients do not like one-step injections and they are less effective

11. General Considerations • 2 step technique • 1 needle, 2 syringes (1 lidocaine syringe, 1 corticosteroid syringe, no mixing)Change syringe between anesthesia-aspiration and injection • 93% of patients prefer the use of lidocaine anesthesia vs. 1-step • Lidocaine creates “a low pressure pocket” at needle tip—hydrodissects and dilates joint space • Low pressure prevents reflux of corticosteroid back along needle track that causes atrophy, maintains more corticosteroid in target, and allows for anesthesia without causing atrophy from steroid administration before joint space is reached • Allows complete aspiration and evaluation of fluid before injecting steroid (complete decompression and aspiration of joint fluid before injection improves response and duration by 20 to 30%)

12. Knee • 21 gauge or 22 gauge, 2-inch needle • 80mg Triamcinolone Acetate • 3-4cc 1% Lidocaine • For aspiration, easiest if patient supine with knee almost fully extended (~10 degrees) • Just posterior to lateral aspect of the patella in the recess behind the patella where a bulge can be detected on exam • Direct posterior and slightly inferiorly

13. Hazardous Anatomy of the Lateral Knee • Superiorly: Superior Geniculate Artery • Medially: Inferior Geniculate Artery • Inferiorly: Anterior Recurrent Tibial Artery

14. Knee Arthrocentesis

15. Preferred Lateral Knee Approach for Arthrocentesis:Suprapatellar Bursa or Lateral Proximal Patellar Lateral Suprapatellar Bursa Lateral Suprapatellar Bursa Lateral Proximal Patellar Lateral Proximal Patellar

16. Knee ArthrocentesisLateral Suprapateller Bursa With the patient supine, a mark is made in the recess (or where there is a fluid bulge) behind the lateral portion of the patella (black), at the proximal edge of the patella. The needle should be advanced 1.5 inches or more until fluid is obtained

17. Knee ArtrhocentesisLateral Midpatellar With the patient supine, the needle is introduced under the patella from lateral to medial, and corticosteroid is injected in the patellofemoral joint (Jackson technique). This is 93% accurate, but not as successful for arthrocentesis.

18. AnteriolateralInferiopatellarBent Knee Approach to Injection Anterolateral portal is defined by the adjoining structures of the inferolateral border of the patella, the patellar tendon, and the lateral tibial plateau. Needle direction is under the patellar tendon, though the anterior fat pad until bevel engages the medial femoral condyle

19. AnteriolateralInferiopatellarBent Knee Approach to Injection Lateral Femur Patella Target Patellar Tendon Tibial Plateau Medial Lateral

20. Bent Knee Anterolateral portal is defined by the adjoining structures of the inferolateral border of the patella, the patellar tendon, and the lateral tibial plateau. Needle direction is under the patellar tendon, though the anterior fat pad until bevel engages the medial femoral condyle

21. Shoulder • 21 gague or 22 gague, 1 ½ or 2-inch needle • 60mg Triamcinolone Acetate • 2-3mg 1% Lidocaine • Patient sitting, shoulder in neutral position • Needle insertion site is 2 cm inferiorly and 1 cm lateral to the choracoid process • Needle direction is posterior and lateral, keeping needle flat (~parallel to ground)

22. Hazardous Anatomy of the Posterior Shoulder • Superior-Medial: Suprascapular Artery • Medial-Inferior: Posterior Circumflex Humeral Artery Posterior Subscapular Approach

23. Preferred Anterior Shoulder Approach:Lateral to Coracoid Process Acromion Target Acromion Clavicle Clavicle Coracoid Process Humeral Head Coracoid Process Target Humeral Head

24. Shoulder Arthrocentesis Anterior approach: The needle is inserted at a point just medial to the head of the humerus, slightly inferior and lateral to the coracoid process (marked in black), which is just inferior to the lateral aspect of the clavicle (marked in black above)

25. Ankle • 22 gauge, 1 ½-inch needle • 60mg Triamcinolone • 2-3mg 1% Lidocaine • Leg-foot angle at 90 degrees • Needle insertion site is just medial to tibialis anterior tendon and lateral to the medial malleolus • Direct needle posteriorly and perpendicular to the tibia shaft

26. Hazardous Anatomy of the Ankle • Distal - Dorsal Artery of Foot • Proximal: Anterior Tibial Artery • Lateral: Fibular Interosseus Artery

27. Ankle Anterior approach (tibiotalar joint): With the ankle at a 90-degree angle to the lower leg, the needle is inserted at a point just lateral to the medial malleolus (black marking) and just medial to the tibialis anterior tendon. The needle is directed posteriorly, perpendicular to the shaft of the tibia

28. Preferred Ankle Approaches:Lateral or Medial Ankle Medial Approach Talus Talus Lateral Approach Tibia Tibia

29. Preferred Ankle Approaches:Lateral or Medial Ankle Tibia Fibula Fibula D. Pedis Artery D. Pedis Artery Lateral Approach Medial Approach Tibia

30. Wrist • 22 gauge-25 gauge, 1 to 1 ½ -inch long • 40mg Triamcinolone Acetate • 1-2cc 1% Lidocaine • Needle insertion site is just distal to radius and just ulnar to the anatomic snuffbox • Direction is perpendicular to the skin • Advance needle approximately 0.75cm until fluid obtained

31. Hazardous Anatomy of the Wrist • Distal - Dorsal Carpal Arch • Radially: Radial Artery • Medial: Anterior Interosseus Artery

32. Preferred Wrist Approach:Directly Distal (1 cm) to Radial Tubercle Ulna Radial Tubercle RadialTubercle Carpal bones Ulnar Head Target Target Carpal Bones

33. Acknowledgements Dr. Wilmer Sibbitt for his teaching and assistance with this presentation

34. References • Kelley’s Textbook of Rheumatology 2008, 20th Edition • UNMH Rheumatology Department • Netter, Frank H. Atlas of Human Anatomy • Up to Date: Joint Aspiration or Injection in Adults: Technique and Indications